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Full text of "A treatise on the practice of medicine (Volume 1)"

VALUABLE MEDICAL BOOKS, 

PUBLISHED BY 

G.RIGG & ELLIOT, 

IVO. 9 i\ORTH FOURTH ISTREET, 

PHILADELPHIA, 

AND FOR SALE BY BOOKSELLERS GENERALLY IN THE UNITED STATES. 



EBERLE'S PRACTICE OF MEDICINE.— A Treatise on the 
Theory and Practice of Medicine, in 2 vols. 8vo. By John Eberle, 
M. D., late Professor of Materia Medica and Obstetrics in the 
Medical Colleges of Philadelphia, Cincinnati, Ohio, and Lexington, 
Ky., &c., &c., with notes and additions by George McClellan, M. D., 
and other distinguished Physicians, embracing all the late im- 
provements and discoveries in Practice. 

This is one of the most valuable works on the Practice of Medicine 
that has ever issued from the American or English press. 

The distinguished editor of the North American Medical and Surgical 
Journal, speaking of this work, says,—" The work of Dr. Eberle is con- 
fessedly one of very great merit. It does much credit to his industry and 
learning, while it places in a very favourable point of view his abilities as 
a practitioner. The talents, industry, and variety of research necessary 
for the production of a system of Practical Medicine, are possessed by few, 
and when we say, as we do with great candour, that the Treatise before us 
will bear a very favourable comparison with any modern work of the same 
class, while it is far superior, as well in regard to the soundness of its 
pathological views, generally speaking, as to the excellence of its therapeutic 
precepts, to the more popular of the English systems, we confer upon it 
and its author no mean praise," 

THE DISPENSATORY OF THE UNITED STATES: con. 
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The above is one of the most valuable works of the kind ever issued from 
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One among the most distinguished of the medical faculty, in noticing the 
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satory of the United States, convinced from our knowledge of its authors 

tl 



GRIGG & ELLIOT'S CATALOGUE. 

that it would prove a most valuable addition to our medical literature. 
We have not been disappointed in these expectations, and feel fully per- 
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The editors of the Journal of Pharmacy observe, as regards the merits ot 
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A TREATISE ON THE MATERIA MEDICA AND THE- 
RAPEUTICS, 2 vols, in one, fourth edition, improved. By John 
Eberle, M. D., late Professor of Materia Medica and Obstetrics m 
the Medical Colleges of Philadelphia, Cincinnati, Ohio, and Lex- 
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Corresponding Member of the Medico-Chirurgical Society, &c. 
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Eberle's Notes for Students, new edition. 

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DR. EBERLE'S works are used in many of our Medical Schools as 
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2 



GRIGG & ELLIOT'S CATALOGUE. 

already appeared, comprising the following divisions ; Anatomy and Phy- 
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4 

u 




A TREATIS 

M 

PRACTICE' OF MEDICINE. 




BY 



JOHN EBERLE, M.D., 

TROKESSOR Oi' THE THEORY AND PRACTrCE OF MEDICINE IN JEFFERSON MEDICAL COLLEGE; 

OF MATERIA MEDICA AND BOTANY IN THE OHIO MEDICAL COLLEi'E ; AND 

OF THE THEORY AND PRACTICE OF MEDICINE IN THE TRANSYLVANIA UNIVEB^^ITY; 

MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; 

OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA; AND 

C0RRE*P0ND1N(; MEMBER OF THE MEDICO-CHIRURGICAL SOCIETY OF BERLIN, IN PKIUSSIA; 

ETC., XTC, ETC. 



WITH NOTES AND ADDITIONS 



BY 



GEORGE M'CLELLAN, M.D. 



IN TWO VOLUMES. 



YOL. I. 



OF 

L. I np ARY 

rv (-0. r- *" 

_ ' i VVvM\ 

PHnritDELJ 

GRKiG AND ELLIOT, 9 NORTH FOURTH STREET. 
1845. 





« 



^^t:^^^ 



« • 

We 

V. I 



Entered according to the Act of Congress, in the year 1845, by 

JOHN EBERLE, M.D., 

in the Clerk's office of the District Court of the United Stales in and for the 

Eastern District of Pennsylvania. 



PHILADELPHIA : 

T. E. & P. G. COLLINS, 

PRINTERS. 



^ 9 



W. 

K 



■^ 



^ 



24919 



TO 

GEOUGE M^CLELLAN, M.D., 

FORMERLY 
PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE, ETC., ETC., 

THIS WORK IS INSCRIBED, 

AS AN ACKNOWLEDGMENT OF THE HIGH REGARD ENTERTAINED FOR THE 

POWERS OF HIS MIND, AND THE GENEROUS SENTIMENTS 

OF HIS HEART, 

BY HIS OBLIGED FRIEND, 

THE AUTHOR. 



PEEFACE. 



In the composition of this work, an effort has been made 
to exhibit a distinct view of the essential phenomena and 
principles pertaining to the various subjects which it em- 
braces, with an especial endeavour to avoid the extremes 
of unsatisfactory bre^vity on the one hand, and of fatiguing 
prolixity of detail and discussion on the other. With the 
exception, therefore, of a few instances in the introductory 
portion of the work, the author has indulged but little in 
controversial discussion and general speculation. His object 
has been, to give a digest of facts and established princi- 
ples, rather than of opinions and points of disputation. He 
has not, however, failed to give an exposition of those 
pathological and therapeutic principles, which appeared to 
him fairly deducible from the particular phenomena brought 
under consideration; and whenever his own experience and 
reflections have led him to diff'er from others, he has freely, 
thouo-h he trusts with becoming deference, stated his senti- 
ments. 

It will be perceived, that no general doctrine or system 
of pathology is exclusively or especially favoured in the 
followino- pages. Medicine, as it is now generally culti- 
vated, is strictly eclectic. The judicious and unprejudiced 
physician will neither condemn nor adopt unreservedly any 
of the leading doctrines advanced in modern times. He 
will see something to admire and embrace in the systems of 
Brown, of Cullen, of Darwin, of Broussais — and even of the 
fanciful Hahnemann ; although when offered to his accept- 



VI PREFACE. 



ance as doctrines of universal application, he may very 
reasonably refuse his assent. 

It will be seen, also, and perhaps by some regarded as a 
defect, that no formal classification has been adopted in the 
arrangement of the work. Nevertheless, the order that has 
been observed in the succession of the various subjects, is 
probably as natural as that obtained by any of the modes 
of systematic arrangement usually pursued in works of this 
kind. It is now generally, and very justly believed, that 
the artificial, classific, ordinal and specific distinctions of 
NOSOLOGY have an unfavoural)le influence on the progress of 
comprehensive and philosophical views in pathology. The 
primary elements of disease, like those of matter, are pro- 
bably but few in number. A few elementary modes of 
morbid action (if the expression may be used) modified in 
their general results or phenomena, by different grades of 
intensity, modes of combination, and the structures impli- 
cated, constitute the fundamental morbid conditions, of 
which the phenomena by which diseases are described, are 
merely the external manifestations. It is here that the 
unfavourable tendency of nosological distinctions mainly 
exists. Instead of leading the student to contemplate the 
morbid symptoms as the mere external expressions or signs 
of disease, modified by various accidental circumstances, 
and especially by the structures chiefly affected, the arti- 
ficial divisions of nosology are apt to lead him to regard 
the groups of symptoms, usually associated, as so many 
distinct essences, possessing fixed and specific peculiarities 
of character. 

To these objections, the arrangements founded on the 
particular structure primarily implicated in the disease, are 
not liable. It must be admitted, however, that correct and 
philosophical as such a classification may appear to be in 
theory, the attempt to reduce it to practice is attended with 
many very serious diflaculties. Nevertheless, should an- 
other edition of this treatise be called for, it is the intention 



PREFACE. Vii 

of the author to arrange its materials upon this plan of 
classification. 

It IS not improbable that various errors may have escaped 
the author's attention in the course of the work ; but he 
has no apologies to offer for any defects it may be found to 
possess; and he sends it into the world, in the hope, that, 
with whatever blemishes and deficiencies it may be charge- 
able, it will be found a useful compilation of facts and prin- 
ciples in pathology and practice. 



EDITOR'S PREFACE TO THE SIXTH EDITION. 



Since the death of the learned author of this work, a 
Sixth Edition has been called for by the repeated demands 
of practitioners as well as students of medicine. Notwith- 
standing the publication of other excellent and popular 
works on the same subject, the credit of Dr. Eberle's Prac- 
tice has been unimpaired. A larger number of copies have 
probably been printed and sold than of any other medical 
book which has been composed in this country. By well 
informed practitioners, this statement cannot be considered as 
an undeserved compliment to the memory of Dr. Eberle. In 
sound medical learning, in judicious criticism, and discrimi- 
nating tact, our author scarcely had his superior. As he 
paid me the compliment of an unsolicited dedication, after 
we had ceased to be colleagues in one of the medical schools 
of this city, it would appear to become my duty to volun- 
teer my services in promoting the publication of this edition, 
by such notes and improvements as the progress of Medical 
Science during the last five years may have suggested. 

GEO. M'CLELLAN. 

Philadelphia, 1845. 



€ONTEOTS OF VOLUME I. 



PRELIMINARY OBSERVATIONS ON THE PATHOLOGY AND 
ETIOLOGY OF FEVER. 

CHAPTER I. 

Page 
Of the Pathology of Fever in General, 17 

CHAPTER H. 

Of the Causes of Fever. 

Sect. I. Of Predisposition, and Predisposing Causes, .... 43 

Sect. II. Of the Sources of Morbific Causes, and their General Character, 46 
Sect. III. Atmospheric Temperature, and its relations with the Animal 

System, - 48 

Sect. IV. Of Miasmata, 53 

Of the relations of Miasmata to the Animal System, &c. - - 62 

Sect. V. Of Contagion, 68 

CHAPTER HI. 

Of the General Course, Type, and Stages of Fever, ... 73 

CHAPTER IV. 
On General Diagnosis, 80 



I.— GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS 
INDEPENDENT OF LOCAL INFLAMMATION. 

CHAPTER V. 
Of Intermitting Fever, ,.. 104 

CHAPTER VI. 
Remitting Fever, ' 128 



CONTENTS. 

Page 
CHAPTER VII. 



Yellow Fevee, 



CHAPTER VIII. 



145 



153 



Continued Fever, .-.-----■ 

Sect I. The Synochal Grade of Idiopathic Fever, or Simple Inflammatory 

Fever, - 157 

Sect II. The Synochus Grade of Idiopathic Fever, - - - " ^"^ 
Sect III. Typhus, ^'''^ 



II.— GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS, CON- 
NECTED WITH OR DEPENDENT ON LOCAL INFLAMMATION. 

CHAPTER IX. 

Of Inflammation in General, 198 

CHAPTER X. 

Of the Phlegmasi.5: of the Aumintary Canal, and its Accessory Organs. 

Sect. I. Of Glossitis, 204 

Sect. II. Of Tonsilitis, 206 

Sect. III. Of Parotitis, 209 

Sect IV. Of Acute Gastritis, 211 

Sect. V. Of Chronic Gastritis, 215 

Sect. VI. Of Acute Enteritis, -..„.... 221 

1. Acute Peritoneal Enteritis, 222 

2. Acute Mucous Enteritis, 229 

Dysentery, 230 

Sect. VII. Of Chronic Enteritis, 244 

Sect. VIII. Of Acute Peritonitis, 248 

Sect. IX. Of Chronic Peritonitis, 256 

Sect. X. Of Acute Hepatitis, 260 

Sect. XL Of Chronic Hepatitis, ----.... 269 

Sect. XII. Of Splenitis, 274 

CHAPTER XI. 

Of the Phlegmasia of the Nervous System. 

Sect. I. Phrenitis, 2^g 

Sect. II. Arachnitis, 282 

Sect. III. Cerebritis — (RamoUissement du Cerveau,) - . . . 295 



CONTENTS. XI 

Page 
CHAPTER XII. 

Of the PHLEQMASIiE OF THE ResPUIATORY OrGANS. 

Sect. I. Pneumonia, - 298 

Pleuritis, 299 

Peripneumonia, . 302 

Pneumonia Biliosa, 302 

Sect. II. Cynanche Laryngea, - - - - - - - - 314 

Sect. III. Cynanche Trachealis, 318 

Sect. IV. Acute Bronchitis, -.-----..330 

Sect. V. Chronic Bronchitis, 336 

Sect. VI. Phthisis Pulmonahs, 346 

CHAPTER XIII. 

Of the PHlEGMASIiE OF THE UrINART AND GenITAL OrGANS. 

Sect. I. Nephritis, . - 360 

Sect. II. Cystitis, 365 

Sect. III. Chronic Cystitis, 367 

Sect. IV. Hysteritis, 370 

Sect. V, Chronic Hysteritis, 374 

CHAPTER XIV. 

Of the Phlegmasia of the Sanguiferous System. 

Pericarditis, (Arteritis, — Phlebitis, &c.) - - - . 377 

CHAPTER XV. 

Of the Phlegmasia of the Fibrous and Muscular Structures, 

Sect. I. Acute Rheumatism, 382 

Sect. II. Chronic Rheumatism, - - - 393 

Sect. III. Gout, 398 

CHAPTER XVI. 

Of the Inflammatory Affections of the Eyes. 

1. Catarrhal Ophthalmia, 412 

2. Rheumatic Ophthalmia, 414 

3. Purulent Ophthalmia, -----.. 415 

4. Scrofulous Ophthalmia, 420 

5. Syphilitic and Strumous Iritis, 424 

CHAPTER XVII. 

Of the Cutaneous Phlegmasije. 

Exanthemata, -- 426 

Sect. I. Variola, 427 



xu 



CONTENTS. 



Page 

441 

Sect. II. Vaccina, ' ^^g 

Sect. III. Modified Small-pox, "'""'"'. 448 

1. Varioloid Affections, ----'* ^,3 

2. Varicella, -----"' ^ ^^g 

Sect. IV. Rubeola, Morbilli, - - - " ' " ' _ ^gg 

Sect. V. Scarlatina, "'* _ ^gg 

Sect. VI. Erysipelas, 

CHAPTER XVIIl. 

Minor Exanthemata. 

T TT .... - 502 

Sect I. Herpes, 

1. Herpes Phlyctenodes, ^"^ 

2. Herpes Zoster, ^0"* 

3. Herpes Circinatis, - ^^^ 

4. Herpes Labialis, - - - ' 507 

5. Herpes Preputialis, 508 

Sect. II. Pemphigus, ^^^ 

Sect. III. Urticaria, ^^^ 

Sect. IV. Miliaria, ■ " - " ' ^^^ 

Sect. V. Lichen, - - - 521 

Sect. VI. Eczema, 524 

Sect. Vn. Erythema, 529 

Sect. VIII. Roseola, 530 

Sect. IX. Purpura, 532 

CHAPTER XIX. 

Vascular Irritations with a flow of Blood. 

Hemorrhages, .- - - -- - - - 537 

1. Epistaxis, 544 

2. Haematemesis, 547 

3. Haematuria, 549 

4. Haemoptysis, 552 

5. Menorrhagia, 558 

CHAPTER XX. 



PHLEGMASIiE OF THE LtMPHATIC SySTEM. 

Phlegmasia Dolens, .... 



563 



A TREATISE 



PRACTICE OF MEDICINE. 



PRELIMINARY OBSERVATIONS ON THE PATHOLOGY AND ETIOLOGY 

OF FEVER. 



CHAPTER I. 

ON THE PATHOLOGY OF FEVER IN GENERAL. 

The history of practical medicine consists of little else than a 
review of the doctrines which have successively risen and sunk again, 
concerning the nature and treatment of fever. Whatever other 
objects of interest or importance within the dominion of medical 
science may have attracted the attention of physicians, fever has at 
all times been viewed as presenting the most extensive and inviting 
field for observation and the exercise of ingenuity. It is in this 
department that observation and research have been most indus- 
trious in accumulating materials, and that hypothesis has luxuriated 
in her wildest exuberance. 

When, indeed, it is considered that the destroying angel has made 
his most desolating visitations under the form of febrile epidemics, 
and that in the long list of human maladies, /ewer occurs in perhaps 
nine cases out of ten, the paramount importance of this subject is 
strongly forced upon our convictions.* 

* " If we except," says Van Svvieten, " those who perish by a violent death, 
and such as are extinguished by mere old age, and which are indeed few, almost 
all the rest die either of fever, or of dsieases accompanied with fever. We read 
in Pliny with what fear and trembling the Romans endeavoured to have this 
universal disease— ^yo", appeased by their supplications in the temple of Fanum; 

VOL. I. — 2 



18 GENERAL PATHOLOGY OF FEVER. 

From a retrospective glance over the history of our science, w 
are forced to acknowledge that there is, perhaps, no subject whic 
is more eminently calculated to humble the pride of human reasoi 
than this one. In relation to this subject, pathology has been in a 
continued state of revolution and instability. The human mmd has 
been engaged with it for near three thousand years. Theories have 
risen and sunk again in a continued and rapid series of succession ; 
each has had its hour " to strut upon the stage," and its votaries to 
yield it faith ; but the stream of time has hitherto overturned all these 
unsubstantial, though often highly-wrought fabrics. 

Has the mind then made no real advancement in relation to the 
pathology of fever ? Are we now no nearer correct and rational 
views concerning this important subject than were our forefathers ? 
Has genius always wandered in idle quest, and brought back no 
substantial trophies from the regions of pathological speculation on 
this point ? Far from it. Like the asymptotes of the parabola, the 
liuman mind is continually verging towards truth, although it may 
never reach it in relation to the essential nature of fever. There 
has probably never been a theory or doctrine promulgated on this 
subject, which did not clear away some old rubbish, or bring to fuller 
view some of the relations of the phenomena it presumed to eluci- 
date. The dreams of speculation have vanished ; but the facts and 
correct principles which were necessarily mingled with them, remain 
as so much valuable treasure saved out of the wrecks of former 
systems. The mass of solid materials which has been thus gradually 
accumulated, has now in a great measure displaced those vague and 
hypothetical foundations upon which former doctrines in relation to 
this subject were constructed. Hypothesis is no longer tolerated in 
science. Philosophy does not acknowledge her as a legitimate ser- 
vant. The cyclus of her empire has gone by ; and the genius of 
rational induction is now the only power under whose direction the 
votary of science presses forward to conquest in the field of know- 
ledge. 

Like many other things which are at once obvious to the senses, 
and concerning the existence of which almost every one can decide, 
fever does not admit of a strictly correct and unobjectionable defini- 
tion ; since there is not a single symptom which is invariably present, 
and which can be regarded as absolutely essential to its existence. 

Boerhaave collected together, from a great number of authors, all 
the symptoms which had been observed in fevers. He then struck 
from this list all those symptoms which did not appear in all, but 
only in certain modifications of fever— retaining such only as, by the 
common consent of authors and his own observations, were found to 

and hence, perhaps, it is, that fevers are called diseases by Hesiod, and that Horace 
calls all diseases simply fevers, when they rushed out of the box of Pandora— 

' Post ignem atherea domo 

Subductum, Macies, et nova febrium 

Terris incubuit cohors.' ''" 

Van Swieten's Com., vol. v. p. 1 



GENERAL PATHOLOGY OF FEVER. 19 

be present in every instance of fever. The result was, that only three 
symptoms were left standing — namely, a quick and frequent pulse, 
preternatural heat of the surface of the body, and a sense of cold or 
chilliness in the commencement. But he might have gone farther, 
and struck from his list these symptoms also ; for it is quite certain 
that cases of fever do occur in which there is neither preternatural 
quickness and frequency of the pulse, nor an increased temperature 
of the surface of the hody ; nor is a sense of chilliness, though perhaps 
the most constant of all the febrile symptoms, universally present in 
the initial stage of fever.* 

Notwithstanding the great difficulty, or rather impossibility, of 
giving a strictly unexceptionable scientific definition of fever, yet 
the train of phenomena which this state of disease presents under all 
its modifications — varying more or less in their concomitance and 
succession — offers, upon the whole, a character sufficiently distinct 
and definite for easy and certain recognition. 

Pathologists have divided fevers — according to the mode of their 
development — into idiopathic and symptomatic, and the propriety 
or impropriety of this division constitutes, at the present day, one 
of the most important, and warmly contested subjects in pathology. 
By the former class, are understood those fevers that are developed 
and sustained by causes, which produce a general morbid state of 
the system, independent of local inflammation or fixed irritation. 
Those who admit the existence of such fevers, suppose that the re- 
mote febrific cause produces a deleterious impression on the sentient 
extremities of the part upon which it acts, which, deranging function 
after function, according to the catenation of the organic sympathies, 
finally results in a state of general disease, characterized by the 
ordinary phenomena of fever ; or, as they presume, the remote cause 
may gradually change the healthy character of the circulating blood, 
which, acting as a morbific irritant on the heart and arteries, gives 
rise to febrile reaction. 

Many eminent pathologists, on the contrary, contend that such 
fevers can have no existence ; and that all febrile excitement is purely 
symptomatic, and of course essentially and wholly dependent on a 
pre-established local irritation or inflammation. According to these 
views, the direct influence of the remote cause of fever is limited 
to the production of the primary local inflammation or irritation, the 
subsequent pyrexial phenomena being the result solely of this pri- 
mary local affection ; in other words, the secondary and sympathetic 
excitement of the pre-established focus of irritation. At the head 

* [In malignant epidemics patients often die in the forming stage of disease, 
before febrile reaction is manifested. Nevertheless the case is pronounced to be 
one of the prevailing fever. Congestive fevers are described by many authors in 
which there was never any development of external heat or excitement of the 
pulse. It is questionable, however, whether this is not too extensive an applica- 
tion of the term. If every condition that precedes or accompanies a fever is to be 
designated by the same epithet^ tliere will certainly be no occasion for the exten- 
sion of nosology. — Mc] 



20 GENERAL PATHOLOGY OF FEVER. 

of those who advocate the exclusive symptomatic nafare of leveT 
Broussais, who, whatever may be thought of his pecuhar cloctrmes 
in relation to this subject, has manifested a professional zeal, ani 
an activity and aciiteness of intellect, which have justly placed mm 
liigh among the ''greater lights" of our profession. Not satisneo, 
however, with the adoption and defence of the general doctrmeoi 
the universality of symptomatic fever, Broussais contends that tne 
inflammation or irritation whence the febrile sympathies radiate as 
from a focus, is almost universally located in the mucous membrane 
of the alimentary canal ; and hence gastro-enteritis is with him the 
yorj 9 e/ or/^o of febrile phenomena. 

That fever is a very common result of local inflammation, is 
unquestionable. So intimate are the sympathetic relations between 
all the various parts of the animal body, that no structure or organ 
can be strongly irritated without causing a sympathetic irritation in 
other organs or structures. If the primary irritation involve the 
sanguiferous capillaries, the irritation will be communicated by sym- 
pathy to the general vascular system, and fever will be the result ; 
but if the local irritation be purely nervous, it will be diff"used, and 
as it were locked up in the general nervous system, and give rise to 
convulsions, or some other form of general nervous affection. Without 
doubt, too, inflammation of the mucous membrane of the alimentary 
canal is much more common in febrile diseases than was formerly, 
and by many, is still supposed. It is even probable that in many 
instances of fever, such an inflammation constitutes the primary and 
essential cause of the febrile phenomena. This is, perhaps, most 
apt to be the case in those instances of fever which result from the 
combined agencies of impure and indigestible diet and atmospheric 
vicissitudes. But although we may admit the correctness of these 
observations, yet to refer all fevers, remitting, intermitting, and con- 
tinued, to ^^astro-enteritis, is as remote from truth as it is detrimen- 
tal in its influence on practice. 

The advocates of the physiological doctrine, as it is called, endea- 
vour to support their sentiments in relation to this subject, by the 
phenomena detected on post-mortem examination, and by arguments 
founded on physiological principles. It is affirmed that marks of 
inflammation almost universally occur in the mucous membrane of 
the alimentary canal, in subjects that die of febrile aff'ections. The 
capillary vessels, to a greater or less extent, of this membrane, it is 
said, are found injected ; and in many instances other and less equi- 
vocal traces of previous inflammation are discovered. Admitting 
that such manifestations of inflammation are as universal as they 
are asserted to be, is there not much reason to believe that, very 
frequently at least, the inflammation supervened during the course of 
the disease, as a consequence of the fever, rather than that the inflam- 
mation was pre-established, and became the immediate excitino' cause 
of the febrile phenomena ? We frequently see inflammations^super- 
vene in parts exposed to observation many days after general fever 
has been fully established. Indeed, when it is considered that in all 
febrile aflections, the secretions which are poured into the intestinal 



GENERAL PATHOLOGY OF FEVER. 21 

tube are unnatural and vitiated — that the process of digestion is sus- 
pended, or much impaired, and consequently, that fermentation and 
decomposition of the contents of the stomach and bowels are espe- 
cially favoured — is there any cause to wonder that we should so often 
meet with traces of inflammation in the digestive organs in those 
who die of febrile affections ? The Broussaian mode of treating 
fevers, although especially meant to obviate such inflammations, ap- 
pears to me, in one respect, well calculated to favour their occurrence. 
The almost total proscription of purgatives from the list of our reme- 
diate means for the treatment of fever, so far from lessening the ten- 
dency to gastro-enteritis, tends, I conceive, in general, to an opposite 
result. In a recent work by Bouillaud, there are upwards of sixty 
cases of fever reported, in not a single instance of which was there 
a purgative medicine administered by the mouth. In all of these 
cases, however, marks of inflammation, and in the majority ulcerations 
ivere detected in some portion of the mucous membrane of the bowels. 
That this should have been observed, will not appear strange, when 
it is considered that in all the cases, most of which continued from 
three to four weeks, all the acrid and vitiated contents of the intes- 
tines were suffered to remain, undisturbed, to act on their delicate 
iining membrane. 

To one not thoroughly imbued with Broussaism, it does appear 
strange that any one should withhold a laxative, under the appre- 
hension of its causing injurious irritation, and yet suffer, without any 
such fears, the most irritating substances to lie quietly in the bowels. 
It is true, laxative lavements were repeatedly resorted to in these 
cases, but that these did not disturb or remove the acrid materials 
ivhich were inclosed iu the bowels, is abundantly manifest from 
what Mr. Bouillaud himself has stated. After having gravely told 
us that in all the cases he describes, the traces of mucous inflamma- 
tion in the bowels were t)'es pronofice, he states that "in general the 
stomach and small intestines were filled lo'ilh a yelloivish or green- 
ish bile, and that the residue of the alimentary substances which 
were found in the small and large intestines, invariably exhaled 
an intolerably fetid smell, and frequently exhibited the consistence 
of mustard. This residue, mixed witii various fluids secreted 
in the intestines, appeared to have iindergone a complete process 
of ])utrpf active decomposition, as was evident from the extreme 
Ojfensiveness of the smell, and the fetid gas which distended the 
bowels^ * 

Can it be reasonably supposed that the transient and moderate 
irritation of a purgative in these cases would have been more in- 
jurious than the constant impressions of the acrid and irritating 
substances which were so long left in immediate contact with the 
bowels ? It is thus, it can hardly be doubted, that many instances 
of gastro-enteritis, so abundant in the practice and dissections of the 
Broussaian school, are developed. Were laxatives employed with 
due moderation, it is probable, that the so much dreaded gastro- 

* Traite Clinique et Experimental des Fievres, Par J. Bouillaud. Paris, 1826. 



22 GENERAL PATHOLOGY OF FEVER. 

eiiterite would, in some instances at least, perhaps in many, 
prevented, and the world deprived of a large proportion ol tno 
triumphant demonstrations which are continually brought out 
formidable array in support of the physiolnsical doctrine. 

As a further offset to the evidence adduced from post-mortem 
examination, it must be observed, that so far as the mere redne.ss or 
injected state of the mucous membrane is concerned, we can draw 
no certain inference as to the previous existence of inflammation in 
this structure. That these phenomena are frequently the result ot 
changes effected in arlicvlo rnortis, or post-mortem, is fully demon- 
strated by the observations of Mr. Yellowly and of Mr. Seeds.* 

* "It must have happened to eveiy one/' says the former of these writers, 
" accustomed to the examination of dead bodies, to see appearances of vascular 
injection in the villous coat of the stomach. Such appearances have very fre- 
quently been referred to inflammation, but they have probably been but little 
studied. I have several times been present at the examination of bodies, where 
the vascularity of the villous coat of the stomach was so considerable as even to 
give rise to suspicions that the appearance had been prodviced by something 
deleterious. I was therefore induced to embrace frequent opportunities of view- 
ing the state of the inner surface of the stomach, and I so often found in it the 
appearances alluded to, as to induce me to imagine, that the opinion which is 
commonly entertained of their being marks of disease, is not well founded. In 
persons suddenly destroyed, when apparently in perfect health, he found the 
mucous membrane of the stomach highly injected." Mr. Seeds, too, found that 
in animals bled to death, the membranous structures frequently exhibit a state 
of injection which might, at first sight, be readily mistaken for inflammation. 

It is well known that the arterial tubes possess a power of contracting to a 
considerable extent, by what Bichat calls the contractility of texture, and that 
this power is not limited to the period of life, but continues some time after 
death. It is equally ascertained that the capUlaries are endowed during life with 
a peculiar degree of sensibility which causes them to resist the entrance of such 
fluids as they are not destined to convey in the performance of their natural 
functions. This peculiar sensibility, by virtue of which the serous capillaries 
refuse, or contract against the intromission of red blood, would seem to depend 
on the regular influx of the nervous influence. That this is the case, appears 
highly probable, if not certain, from the different results arising from the forci- 
ble injection of fluids into the arteries of living and dead animals. " Push into 
the aorta of a living animal, by means of a syringe, different fine fluids, and you 
will never see them fiU the capillary system, or issue by the exhalents ; " when, 
however, the same experiment is performed on an animal soon after death the 
fluid will be found to pass readily into the serous capillaries, and pass out by 
the exhalents, excretory ducts, &c. (Bidiat.) Mr. Buniva's experiments quoted 
by Bichat, with injections upon dead and living animals, illustrate this fact in a 
very striking manner. He fixed the pipe of a syringe into an artery of a livin"- 
animal; on endeavouring to force the fluid into the vessel he found very o-reat 
resistance, the piston passing down very slowly, and only with the application 
of much force. On causing die animal to be suddenly killed, by dividiu"- the 
spinal marrow just below the occiput, the fluid passed rapidly out of the svr" 



GENERAL PATHOLOGY OF FEVER. 23 

Broussais and his followers are, indeed, fully sensible of the 
observation of Celsus : Neque qiiicqnam esse stultius quam quale 
quid iHvn homine est, (ale existimare esse moriente imo jam mor- 
iuo ; for where they fail in detecting a red and injected stale of the 
mucous membrane of the bowels, they account for its absence by 
ascribing it to a post-mortem change ; thus availing themselves of 
this fact when it affords an argument in their favour ; whilst they 
manifest an unwillingness to allow any importance to it when it is 
adduced against their doctrine. 

It cannot, indeed, be presumed that the injected state of the mu- 
cous membrane of the intestinal tube, so often discovered in those 
who die from fevers, is always, or even generally, to be ascribed to 
a mere post-mortem change; but that such changes do sometimes, 
nay, often occur, and that they have been assumed as evidences of 
previous inflammation, there can exist but little doubt. 

The first obvious effect of the remote febrific causes, consists 
almost universally in a diminution of the nervous energy, and con- 
sequently of the action of the heart and arteries. This is manifested 
by the weak and contracted pulse, the general langour and lassitude, 
the diminished temperature and the sense of chilliness which usher 
in all febrile affections. These initial plienomena of fever are espe- 
cially conspicuous in intermittents, remittents, and in catarrhal affec- 
tions. There is nothing in the character of these symptoms which 
can justify the inference that they are dependent on inflammation. 
"Inflammation," says Dr. Armstrong, "cannot exist in the cold 
stage of fevers, all the phenomena of which are directly opposed to 
inflammation." The course and phenomena of intermitting fevers 
present us, indeed, with insurmountable objections to the '■'jyliysi- 
ological dactrineP The periodicity of these fevers is strongly 
opposed to the idea of their immediate dependence on the gastro-ente- 
ritis. It is, indeed, true, that aftections of an inflammatory charac- 
ter have been known to recur in a strictly periodical manner ; but 
such cases must be viewed as anomahes, and altogether contrary to 
the almost universal course and character of phlegmasial diseases. 

into the artery, although but Uttle force was applied. While the capillaries 
retained their full portion of vitality, they resisted the introduction of the fluid ; 
but as soon as they had lost their sensibility, in the death of the animal, they 
yielded like passive tubes to the fluid forced upon them by the vis h tergo. The 
application of these facts to the post-mortem production of a red and injected 
state of the membranous structures, especially the more vascular ones, is easily 
to be understood. So long as the serous capillaries retain their vitality, they 
resist the entrance of red blood into them. As soon, however, as their vital pro- 
perties cease to exist, they lose the power of resisting the intromission of red 
blood — becoming, in fact, mere passive and yielding tubes. But as the arteries 
continue to contract on their contents, some hours after the extinction of life, 
they must necessarily force the blood forward into the relaxed and unresisting 
capillary system, into which it wiU therefore be driven, as into a sponge, and 
give to the more vascular structures, the red and injected state, so often found on 
post-mortem examination, where no previous inflammation whatever existed. 



24 GENERAL PATHOLOGY OF FEVER. 

An inflammation which observes a perfect periodicity ui its ^^^^^.^' 
must be .mi generis. If intermitting fever depend on "1"^"^"^^ ^^^3 
of the mucous membrane of the ahmentary canal, then mus 
inflammation be periodical, and therefore essentially distinci n^oi_i 
the inflammation which produces remit ling fever; lor "^ 
malady it must be continuous. These two forms of fever are, now 
ever, produced by the same remote cause ; and we are tnereiore 
forced to admit, by the assumption of this doctrine, that the same 
remote cause is capable of producing two kinds of inflammation 
essentially distinct from each other. The character of the remedies, 
too, which have been found most effectual in arresting intermitting 
fever, is directly opposed to the idea that gasiro-enteritis constitutes 
its proximate cause. Who can believe that quinine, arsenic, black 
pepper, and other remedies of a similar character, are peculiarly 
calculated to cure inflammation of the mucous membrane of the 
alimentary canal? Indeed, these very articles appear to be par- 
ticularly dreaded by the disciples of this doctrine, on account of their 
tendency to create gastro-onteritic irritation, and yet all experience 
goes to prove that they are decidedly the most prompt and valuable 
means for the cure of intermitting fever. 

M. Broussais' theory of the mode in which the remote causes of 
febrile affections produce gastro-enteritis is gratuitous, and but little 
calculated to satisfy the understanding, "Every irritation," he 
says, " which is capable of producing a perception in the brain, 
passes back by the nerves to be repeated in the mucous mem- 
braties.'^ Thus, if a person be inoculated with small-pox virus, the 
irritation of the primary pustule, or of the inoculated point, is con- 
veyed to the brain, whence it is reflected by the nerves upon the 
mucous membranes of the alimentary canal, where it establishes an 
inflammation. This intestinal inflammation constitutes the essential 
cause of eruptive fever, and the eruption itself is only a metastatic 
disorder of the cutaneous system. The assumption, then, " that every 
irritation which is capable of producing a perception in the brain, is 
reflected by this organ to be repeated in the mucous membranes 
of the alimentary canal, forms the main principle in the Broussaian 
doctrine of the etiology of fever. That the mucous membranes 
of the intestinal tube possess a very wide sphere of sympathetic rela- 
tions, is a fact indeed as undeniable as it is important in a patholo- 
gical point of view. But that this structure constitutes a subordinate 
sensorium commune, to which all morbific impressions are especially 
conveyed, after having been perceived by the brain, is a position 
which all the zeal and ingenuity of its advocates have as yet failed, 
and I apprehend will ever fail, to place upon that firm basis which 
it ought to have to serve as a foundation of our pathological faith. 

I do not mean to object to the general fact, that all impressions 
capable of ultimately exciting fever, are in the first place communi- 
cated to the sensorium commune, and thence reflected throuo-hout the 
system, and sometimes upon some particular organ or structure • hvbt 
this reflected impression does not, it may be justly maintained necesr- 



GENERAL PATHOLOGY OF FEVER. 25 

sarily, establish a focus of irritation, nor always, or even generally, 
fall especially npon the intestinal mucous membrane. 

If the impressions of morbific causes are always transferred to the 
mucous membrane of the alimentary canal, the impressions of all 
agents, remedial as well as others, must of conrse be referred to the 
same structure. This, however, does not accord with the results of 
observation. When mercury is rubbed on the skin, the salivary 
glands, the gums, and the mucous membrane of the mouth, receive 
the chief impressions excited by this agent. Will it be contended 
that a gastro-enteritis must be established before salivation can be 
produced? If opium be applied to any part of the body, the im- 
pressions are concentrated in the nervous centre. When cantharides 
are applied to the surface, the irritation is conveyed to the neck of 
the bladder, and not to the mucous membrane of the bowels, and 
yet fever may be the result. From these and many other similar 
facts that might be adduced, it is manifest that the supposed law of 
the animal economy, by which, as is alleged, all febrific impressions 
are reflected from the brain and repeated in the mucous membranes 
of the bowels, is gratuitous, or to say the least, highly improbable. 

The fallacy of those doctrines which confine the primary inflam- 
mation to some one structure exclusively, is strikingly illustrated 
by the circumstance, that diff'erent writers have fixed on different 
structures, as the parts primarily affected in fevers. Thus Clutter- 
buck maintains, with Broussais, that fever is always a purely symp- 
tomatic affection depending on local inflammation pre-established 
by the febrific cause. He asserts that this primary inflammation is 
invariably located in the brain and its membranes, and adduces the 
phenomena discovered on post-mortem examination, in testimony of 
the correctness of his doctrine, Broussais, on the other hand, asserts 
that the primary inflammation is not in the brain, but in the mucous 
membrane of the bowels, and appeals with equal confidence to the 
appearances exhibited on dissection for confirmation of his doc- 
trine. 

This discrepancy is in itself sufficient to show the weak foundation 
on which these two doctrines rest; for if the evidence afforded by 
autopsic inspection in relation to this subject were not extremely 
ambiguous, it would, one may suppose, be impossible to draw from 
it conclusions so very discrepant, and yet so nearly equal in point of 
plausibility. 

The advocates of the gastro-enteritic pathology of fever place no 
inconsiderable reliance for support to their doctrine on, what they are 
pleased to assert, their superior success in their remediate manage- 
ment of fevers. Leeches, and an almost total abstinence from food, 
with cooling, acidulated, nuicilaginous drinks, constitute nearly the 
whole of their remediate applications ; and they claim for this mode 
of treatment, a greater success than that which they allow to others 
who pursue a more active course of treatment in fevers. It does not 
appear, however, that the golden age of medical success, so confi- 
dently promised by Broussais, on the introduction of his doctrine, has 



26 GENERAL PATHOLOGY OF FEVER. 

as yet arrived;* for the statements which have been published in 
France, in reference to the comparative mortality under the liioiis- 
saian, and the other modes of treatment, give no support to the claims 
of superior success set up for the former. We might, however, admit 
the excellence of the Broussaian mode of treating fevers, witliout 
yielding our assent to the correctness of the doctrine that the gastro- 
enteritis is primary where it dop.s exist. There exists but little doubt 
in my mind, that in continued and remitting fevers, active purgation 
is not unfrequently carried to an injurious extent; for, although we 
may, and, as I conceive, ought, to reject the opinion that such fevers 
depend essentially on the gastro-enteritis, yet we cannot doubt, that 
a very considerable degree of irritation, amounting in many instances 
to inflammation, does often supervene during the progress of the dis- 
ease, as an epiphenomenon, and unconnected with the origination of 
the fever. In cases where such a condition of the mucous membrane 
of the intestinal canal occurs, during the course of the disease, the 
soothing treatment recommended by Broussais, is no doubt more 
salutary than the vigorous purgative plan so commonly pursued in 
this country and in England. Unquestionably, intestinal irritation 
and inflammation perform an important part in febrile diseases. 
These conditions may arise as consequences of the general febrile 
reaction, as well as from harsh and repeated purgation, and the use 
of other irritating remediate agents. But it is equally probable that 
gastro-enteritis is often excited by acrid and vitiated secretions, and 
other offensive materials retained in the bowels in consequence of 
withholding suitable laxatives, in the commencement and during the 
progress of the malady. Broussais has done much good, by awaken- 
ing the attention of the profession to these pathological conditions; 
and thus furnishes another proof of the fact, that new doctrines, 
though fundamentally erroneous, seldom fail to do some good, by 
directing the views of physicians to important circumstances, which 
were previously overlooked, or too much neglected. 

In leaving this subject, I deem it right to observe, that however 
widely we may differ from Broussais in relation to the pathology of 
fever, all must admit that he has just and high claims to the respect 
and gratitude of the profession for the light which he has thrown on 
the nature, symptoms and treatment of mucous intestinal inflamma- 
tion, as well as on the physiological and morbid sympathies of the 
animal system. 

Broussais is unquestionably one of the most enlightened and inge- 
nious pathologists of the present day. His is now the only general 

* In 1821, Broussais asserted "that the tables of mortality declare in favour of 
the new doctrine, and that its infiuencc upon population would he more favourable than 
that of the introdudion of vaccination/' Unfortunately, however, this happy influ- 
ence of thenoMue//e doctrine, remains yet to be realized;! and the advocates of the 
doctrine may console themselves for the tardiness of this influence, with the cer- 
tain prospect of not being very soon deprived of the opportunity of publishin'- 
their ordinary quantimi oi post-mortem examinations. ' 

t Refutation de la Doctrine de M. L. Doct. Broussais, par L. Castel. 



GENERAL PATHOLOGY OP FEVEB. 27 

doctrine which especially occupies the attention of the profession. 
Like all the preceding great doctrines in medicine, it is destined, 
perhaps, to culminate for a while in the firmament of our science, 
and to attract its host of worshipers ; hut, assuredly, sooner or later 
it must sink again, and add another to the long list of once highly- 
favoured, but now exploded and neglected doctrines. That the 
Broussaian system contains much that is valuable, it would be un- 
just to deny ; but to these concessions in its favour, there are, unless 
the majority of competent judges greatly err, offsets of no small 
moment. In relation to this doctrine, as indeed to every one else, 
it behooves us to embrace the useful and reject the false ; in short, to 
adopt the good advice of Lucretius,* 

'•' doctrinam acri 



Judicio perpende ; et si tibi vera videtur 

Dede manus — aut si falsa est, accingere contra." 



Having now given a summary of the principal objections which 
may be urged successfully, I conceive, against the " new physiological 
doctrine," I proceed to an exposition of the following propositions, as 
embracing the leading, and it is believed, tenable points of doctrine, 
in relation to the mode of origin and character of febrile diseases. 

1. Fever is a general disease — the sanguiferous system being essen- 
tially and predominantly disordered. 

2. The morbid vascular excitement of fever is located, essentially, 
in the capillary system of blood-vessels — consisting in in'italion, and 
not in mere increased or decreased action. 

3. This irritated excitement may be the result of morbific causes 

[* Clutterbuck's opinion, published in 1807, gave origin to the doctrine that fever 
is not a primary affection; but essentially a local inflammation; the seat of which 
is in the brain. Frank, of Vienna, attributed fever to an inflammation of the 
arterial system ; and some of the Italian physicians extended the same idea to the 
inner coat of the vaia porta. The advocates of the non-essential doctrine of fever, 
however, have chiefly proceeded on the foundation of Broussais. As often as they 
have been able to detect any trace of morbid alteration of structure in the intestinal 
canal, after the termination of a fever, they have attributed the general disorder 
to a local cause. It had long been known that the glands of Peyer and Brunner, 
in the mucous coat of the small intestines, were liable to inflammation and even 
ulceration. But it was reserved for the celebrated Louis, of the Hotel Dieu, in 
Paris, to discover that such a condition of these small glandular follicles, espe- 
cially the conglomerate ones, was the true cause of one of the most frequent forms 
of fever. The progress of pathological anatomy has imquestionably developed 
new and important facts ; but we may doubt whether it has not of late given a 
wrong direction to medical inquiry. Effects and concomitant phenomena are 
perpetually mistaken for causes. It would not surprise us if some writer should 
come out with the doctrine that cutaneous eruptions and scabs, and that buboes and 
carbuncles, are tlie true causes of the small-pox and plague. — Mc.] 



28 GENERAL PATHOLOGY OF FEVER. 

acting directly on the internal surface of the sanguiferous ^=7^^^"^^'^^' 
of irritating impressions conveyed sympathetically to this sy ? 
from a primary focus of irritation. • .u 

4. The first link in the chain of morbid actions, which occui in uie 
development of fever, always commences in the nerves. 

5. The remote or exciting causes of fever rarely Foa"c^ locai 
inflammation, anterior to the development of the general lebriie leac- 
tion. Their action is confined to the production of morbia impres- 
sions on the nerves, which, passing inwards to the brain, usually cause 
a temporary depression of its energies, and consequent disturbance 
in the equilibrium of the nervous and vascular excitements ; at the 
same time that the morbid impressions reflected by the brain through- 
out the system, contribute to the functional disturbance and irritation 
of certain internal organs or structures. 

6. Although local inflammation is not essential to the production 
and support of fever, yet, in many instances of idiopathic or general 
fever, more or less inflammation supervenes, after the febrile reaction 
is established ; and occasionally the development of the febrile excite- 
ment and local inflammation is efl'ected simultaneously. 

7. Inequilibrium of excitement, and local determinations of blood, 
constitute an important characteristic of fever; for, although strictly 
a general malady, there are always some organs or structures in a 
state of increased morbid excitement, whilst, at the same time, others 
are in an enfeebled, languid or torpid condition. 

In stating that fever is a general malady, it is not presumed that 
every structure of the organization is in a state of actual disease; but 
as the nervous and vascular systems are so intimately concerned both 
in the composition and functions of every part of the body, it may 
well be inferred, that where these two systems are in a morbid con- 
dition, as they manifestly are in fever, every other irritable and sensible 
structure must suffer more or less functional derangement. Never- 
theless, it cannot be questioned that the essential morbid excitement, 
which constitutes fever, is located in the sanguiferous system. The 
disordered action of the heart and arteries — the increased temperature 
of the body — the altered state of the secretions — the morbid appear- 
ances on dissection — and, in most instances, the changed state of the 
blood, aflbrd sufficient evidence of the paramount disorder of the 
blood-vessels in febrile affections. 

The morbid vascular action of fever is an irritated and not a mere 
increased action of the heart, arteries and capillaries. There exists a 
wide difference between irritation and mere excitation. The for- 
mer is the result of stimuli acting either directly or indirectly upon an 
organ or structure, whose vital properties are in a derano-ed or mor- 
bid condition ; and is therefore always essentially connected with a 
disordered state of the nerves of the part affected. This result is not 
simply a greater or less degree of the natural or healthy excitement 
but an action or excitement essentially morbid or distinct from healthy 
action. Mere excitation, or increased action, on the other hand is 
the result of stimuli acting on an organ or system whose vital pro- 
perties remain in a healthy or underanged condition. A few ounces 



GENERAL PATHOLOGY OP FEVER. 29 

of alcohol, for instance, will cause a high degree of arterial action in 
an individual not accustomed to this stimulus; and the same effect 
will be produced by any sudden and violent bodily exertion, as run- 
ning, rapid walking, &c. Here, then, there is increased action of the 
heart and arteries, with an augmented state of the animal tempera- 
ture ; but this does not constitute fever. The vital properties remain 
in their normal condition, and the organs thus inordinately excited, 
return to their natural and healthy grade of action, as soon as the ex- 
citing cause ceases to act. As, however, all excessive action tends to 
weaken, and finally to derange the vital properties of the over-excited 
parts, so, when such stimuli are very protracted in their influence, 
they may, at last, disorder these properties and give rise to fever. 
Without such a derangement or morbid condition of the sensibility 
and irritability of the heart, arteries and capillaries, no fever can 
occur ; for so long as the vital properties are in their natural state, all 
irritants or stimuli can produce only a greater or less degree of nor- 
mal excitement, and the secretions will be diminished or increased, 
but not depraved. As soon, however, as these properties have de- 
parted from their healthy condition, every stimulus, whether natural 
or morbific, must necessarily excite morbid actions. Hence, it may 
be concluded that every cause which produces fever, in whatever 
way its influence may be conveyed to the sanguiferous system, must 
necessarily derange its vital properties, either directly or indirectly, 
before that general irritated vascular action which constitutes fever, 
can be established. 

It is evident, therefore, that although the characteristic pheno- 
mena of fever depend on morbid action of the heart, arteries and 
capillary vessels, the nerves also are essentially and primarily disor- 
dered in febrile diseases; for irritation, as has just been observed, 
necessarily implies a morbid or deranged condition of the vital pro- 
perties, and it cannot be doubted that, so far, at least, as the capillary 
system is concerned, these properties are derived immediately from 
the nerves. 

From a careful analysis of the phenomena of fever, it would ap- 
pear that, although the sanguiferous system, generally, is prominently 
disordered in fever, yet the essential febrile excitement is especially 
located in the capillary system of blood-vessels. Fever cannot exist 
without capillary irritation or derangement of the secretory and ex- 
cretory functions. So long as the capillary functions remain free from 
morbid excitement, or the principal secretions continue to be per- 
formed in a healthy manner, no increased action of the heart and 
arteries can constitute fever, but only an over-excited state of these 
organs, which will subside when the exciting cause is removed. A 
person who is thrown into a violent gust of passion, experiences 
vehement action of the heart and arteries; but unless the capillary 
vessels are brought into a state of morbid excitement, or irritation, it 
will not be fever, but simple super-excitation.* On the other hand, 

* Some of the sentiments stated in this chapter; do not differ materially from 
those given by Dr. Southwood Smith, in his interesting work on fever. The views 



30 GENERAL PATHOLOGY OF FEVER. 

marvfesi disorder in the action of the heart ^'^"^1,''^^'^^'*^^' f|^e most 
appear to be essential to the existence of (ever. Fevers o ^ 
malignant and fatal character-attended with "'^^q^^^^^r^T n, f n 
tions of capillary disorder, such as hemorrhage, P^tecHias ji ^ 1 1- 
flammationrnot imfrequently occur, in which no obvious deviation 
from the natural action of the heart and arteries can be detected^ 
Dr. Smith, in his very valuable treatise on iever, observes, ttiat tie 
order in which the morbid actions which constitute fever, occur, 
" is, first, derangement in the nervous and sensorial lunctions ; m s 
is the invariable antecedent ; secondly, derangement in the circulat- 
ing function : this is the invariable sequent : and thirdly, derangement 
in the secreting and excreting functions : this is the last result in the 
succession of morbid changes. Derangement m the functions ot 
secretion and excretion never comes first in the series : derangement 
in the nervous and sensorial functions never comes last in the series : 
derangement in the function of the circulation never comes either 
first or last in the series, but always the second in succession." 

That derangement of the nervous system constitutes the initial link 
in the chain of morbid actions which occur in the development of 
fever, cannot be doubted. The mental and muscular languor— the 
general malaise and uncomfortable sensations— the pains in the 
loins and extremities— the morbid sensibihty to low temperature— the 
dejection and irritableness of temper, and the confusion and weak- 
ness of the intellectual powers, which so universally usher in febrile 
diseases, afford unequivocal evidence of pervading derangement in 
the nervous system. 

In relation to the subsequent order of the morbid changes which 
supervene in the development of fever, however, we cannot adopt 
the sentiments expressed by Dr. Smith. The assertion, that the heart 
and arteries are universally and necessarily deranged, next in order 
to the primary disorder of the nervous system, and before the capil- 
lary or secretory extremities of the blood-vessels are brought into a 
state of morbid excitement, appears, I think, contrary both to correct 
physiological principles, and to the results of observation. It is well 
known that the extreme vessels, the secreting capillaries, are incom- 
parably more closely connected with, and dependent for their func- 
tions on, the nervous system, than the heart and larger blood-vessels. 
It is scarcely necessary to refer to the experiments of Wilson Philip 
and other modern physiologists in support of this observation. From 
this physiological principle alone, then, we would be led to infer, that 
the extreme vessels — those which are immediately, or at least very 
intimately, concerned in the process of secretion and calorification — 
would be the first to suffer derangement of function from general 
morbid excitement of the nervous system. That capillary derange- 
ment is, in fact, the immediate sequent of the primary functional 
disturbance of the nervous system in the evolution of fever appears 
to me sufficiently demonstrated by the phenomena presented in the 

here given, whether correct or incorrect, I have taught in my public lectures for 
seven years past. 



GENERAL PATHOLOGY OP FEVER. 31 

forming stage of the disease. Who does not know that torpor of the 
ciUaneons exhalents is one of the most common initial symptoms of 
fever ? This function is frequently prominently deranged, before any 
manifestations of the morbid action of the heart and arteries can be 
detected. When kiono-miasmata acts slowly upon the system, we 
often find, along with the above-named symptoms indicative of dis- 
ordered nervous excitement, decided evidence of functional derange- 
ment of the liver, as well as of the perspiratory vessels. The utter 
groundlessness of Dr. Smith's sentiments on this point, may, indeed, 
be predicated on the simple circumstance, that it has led him, neces- 
sarily, to deny, that pneumonia, hepatitis — in short, all the alFections 
embraced under the general term p/i/esrmasia, are fevers! Believ- 
ing, as he does, that the order of morbid changes, from the nerves to 
the heart and arteries, and finally, to the secretory capillaries, is uni- 
versal, and as invariable as the laws of nature, he is, of course, 
obliged to deny the name of fever to the general sympathetic pheno- 
mena which occur in consequence of local inflammation — for in these 
symptomalic fevers the successive morbid changes occur, he says, in 
a different order. " Febrile diseases," he observes, " are commonly 
divided into idiopathic and symptomatic — a division which is liable 
to the fundamental objection, that the diseases included under the 
second head are not fevers, but inflammations. There are no fevers, 
but idiopathic fevers.''"' And the reason why the general symptoms 
of the phlegmasia do not constitute fever is, he says, because " in 
pneumonia, in enteritis, in hepatitis, &.C., the spinal cord and the brain 
are never the organs in which \k\Q first indications of disease appear ; 
the earliest indications of disease that can be discovered, having their 
seat in the affected organ itself, and it being only after the disease has 
made some progress, that the other organs (the heart and arteries, 
and the brain) and functions are involved." Ingeniously as Dr. 
Smith has argued upon this subject, very few, it may be presumed, 
will agree with him in denying, that the general morbid actions 
arising from local inflammation, are truly and essentially febrile. In 
truth, however, the alleged diversity in the order of the morbid 
changes of idiopathic and symptomatic fevers, has no existence. 
Local inflammation, like every other exciting cause of fever, that 
does not act directly on the heart and arteries, can affect the general 
system only through the medium of the nerves; and hence, we 
almost invariably find the same train of symptoms accompanying the 
rise of fever from inflammation, as is known to usher in idiopathic 
fever. What do we observe when fever comes on from a wound? 
The patient, at first, experiences some degree of febrile languor — 
accompanied with a sense of slight chilliness, malaise; and derange- 
ment of the exhalent functions of the skin. These symptoms, though 
often so slight and transient as to be scarcely perceptible, invariably 
precede the occurrence of the febrile reaction of the heart and arte- 
ries ; and hence the order of sequence in the morbid actions, which 
take place in the development of symptomatic fever, does not differ 
from that which obtains in idiopathic fever. The nerves always 
receive the first shock and morbid change. This speedily gives rise to 



I 



32 GENERAL PATHOLOGY OF FEVER. 

more or less conspicuously deranged action of the secretory capilla- 
ries — and finally the heart and arteries are morbidly excited. ^ 

While Dr. Smith, more confidently than prudently asserts, tnat 
" there can be no fever but idiopathic fevers," Broussais and "is dis- 
ciples assert, that " the existence of idiopathic fever is impossible. ' 
Such are the contradictory extremes to which theory is apt to lead 
the understanding ! That fever may occur both with and without 
local inflammation, may be disputed by theorists, but cannot be 
doubted by those who observe diseases with unbiased judgments, in 
the hght of common sense. 

It must, indeed, be admitted, that local irritation or local morbid 
action invariably occurs, as the initial morbid condition, whence the 
series of consecutive deranged actions in the evolution of fever have 
their origin. This admission does not imply a concession in favour 
of the Broussaian doctrine, since it is predicated, in part, on the 
demonstrable position that the local morbid excitement is not unfre- 
quently located in a greater or less extent of the lining membrane of 
the blood-vessels themselves, and produced by irritating agents admit- 
ted into the circulation from without, or by retained recrementitious 
elements acting directly on the internal surface of the sanguiferous 
system.* It appears to me that there is no pathological fact which 
is more susceptible of satisfactory illustration, than that fever fre- 
quently arises from morbific causes acting immediately on the san- 
guiferous system, and establishing a primary irritation in a greater or 
less extent of its internal lining membrane. 

Without denying the all-pervading influence of that principle of 
the living system, called sympathy — or still more comprehensively, 
without denying that all the phenomena of life, whether of health 
or disease, are but so many manifestations of the action of the living 
solids, it is a truth equally undeniable, that the blood may and does 
frequently serve as the medium through which deleterious agents act 
immediately on the heart and arteries, and thus give rise to febrile 
phenomena. " The venous system," says Bichat, " may be regarded 
as a general reservoir, into which are poured all the materials which 
are to be thrown out of the body, and all those which are to enter it. 
In this last respect, this system of vessels performs an essential part 
in the production and support of diseases. The deleterious sub- 
stances may be introduced into the blood-vessels with chyle, and 
produce ravages in the system in circulating with the fluids. There 
can be no doubt, moreover, that, besides the principles which convert 
the venous into arterial blood, there often passes through the lungs 
into the circulation, deleterious miasmata, which produce diseases, as 
my experiments on asphyxia have proved. The intestines, the lungs, 
and the skin are the three avenues through which the morbific agents 
may gain admission into the circulation."! 

That foreign substances are readily taken up by the absorbents 

* M BouiUaud, whose work I have already mentioned, advocates this view of 
the etiology of certain varieties of fever. 
t Anatom. Gener., vol. i. p. 284. 



GENERAL PATHOLOGY OF FEVER. 33 

and veins, and conveyed into the circulation in an unassimilated 
state, is now no longer a subject of doubt or dispute. It appears 
to me highly probable, that miasmatic agents act upon the animal 
system, in part at least, by being admitted through the lungs, into the 
current of the circulation. Some contend that these aerial morbific 
causes act primarily on the stomach. It is asserted, that the miasma, 
becoming entangled in the saliva, and swallowed with this fluid into 
the stomach, establishes a primary morbid impression in its delicate 
mucous membrane. It is alleged, in confirmation of this opinion, 
that the stomach, possessing a very extensive circle of sympathetic 
relations, and being highly sensitive to impressions, is peculiarly 
calculated to become the primary focus of morbid excitement from 
external morbific causes. It is affirmed, moreover, that the initial 
symptoms of fever point out the primary influence of the febrific 
cause on the stomach. The depressed or abolished appetite, the nau- 
sea and vomiting, and the peculiar sense of uneasiness in the epigas- 
trium, are considered as afibrding strong evidence of the correctness 
of this opinion. It is asserted, finally, that the lungs are endowed 
with an inferior degree of sensibility, and that their sympathetic 
relations are by no means very extensive, and that, therefore, they 
are but imperfectly adapted for receiving and propagating morbid 
impressions from external causes. 

In reply to these arguments, it must be observed, that it does not 
seem probable that a sufficient quantity of miasmata could gain ad- 
mission into the stomach to produce disease. As to the evidence 
drawn from the character of the premonitory symptoms, it cannot 
afford any available support to this doctrine. A severe wound, or 
contusion, will give rise to nausea, vomiting, and immediate loss of 
appetite. Such phenomena only show that the stomach readily 
sympathizes with impressions made on every part of the body, when 
of sufficient degree of intensity. With regard to the alleged insen- 
sibility of the lungs, or their limited sphere of sympathy, we might 
admit its justness without being reduced to the necessity of adopting 
the opinion that miasmata act primarily on the stomach. It is not 
presumed that aerial morbific agents act simply on the nervous ex- 
tremities of the respiratory passages, and thus give rise to a chain of 
sympathetic morbid actions. It is contended, that agents of this 
kind pass through the lungs into the current of the circulation, or 
effect certain morbid alterations of the blood, in consequence of 
which, the lining membrane of the heart, arteries, and capillary sys- 
tem is irritated, and the vascular system thrown into a state of 
febrile excitement. That agents of this kind are absorbed into the 
circulation, and act upon the system through the medium of the 
blood, may be inferred from a number of familiar facts in relation 
to the inhalation of odoriferous effluvia. The inhalation of the fumes 
of turpentine, of garlic, and of various other substances of a similar 
character, is speedily followed by the manifestation of these odours 
in the urine. How are we to account for the extraordinary effects 
which arise from the inhalation of nitrous oxide, and of the vapour 
of sulphuric ether ? It does not seem probable that these effects are 

VOL. I. — 3 



34 GENERAL PATHOLOGY OF FEVER. 

produced by the mere action of these causes on the P"'^"^^" ^J^^ 
nerves ; for when these substances are taken nito the st^"^^"- ' 
nerves of which are so highly sensitive, no such consequences . 

These focts go to show, that substances capable ot .^^f ""^ J; ^ 
animal economy, will, when admitted into the lungs in ^ gaseous 
form, promptly and powerfully exert their pec"l>ar infl^^^nce upon 
the system, there are no good grounds, therefore, ^^^.^^^^ "§ ^,^J 
miasmata and contagious effluvia may produce their (deleterious 
effects through the sSme avenue. The bronchial tubes and cells 
expose a very extensive surface to the impressions or absorption o 
such agents ; a circumstance which, it may be presumed, is well 
calculat^ed to favour their morbific influence on the system. Ihe 
experiments of Magendie, in relation to the effects of putrid effluvia 
on the animal system, may also be cited in favour of this opinion. 
On exposing animals to the inhalation of putrid effluvia, some suf- 
fered no injury, whilst others rapidly emaciated, and died at different 
intervals within twenty days. When, however, the putrid sub- 
stances, from which the effluvia experimented with emanated, were 
introduced into the stomach, no obvious inconveniences were expe- 
rienced by the animals.* To these facts we may add, that small- 
pox virus, when swallowed into the stomach, will not, or, at all 
events, extremely seldom, infect the system ; whereas every one 
knows how readily the disease is communicated by inhaling the 
effluvia which emanate from the bodies of those who labour under 
the malady. 

It appears very evident, therefore, that aeriform febrific agents act 
upon the system through the medium of the respiratory organs ; and 
the facts just mentioned render it highly probable that they enter 
into the current of the circulation, and act immediately on the inter- 
nal surface of the heart, arteries and capillaries, perhaps more com- 
monly on some portion of the latter set of vessels. 

It is not presumed, however, that agents of this kind always, or 
perhaps at any time, act exclusively through the medium of the 
blood, in the way just stated. Any part of the organization which 
exposes a sensitive surface to the impressions of such causes, may, 
no doubt, enable them to operate injuriously on the general system. 
All that is here contended for is, that morbific agents of every kind, 
but especially gaseous substances, do often pass into the circulation, 
and that being thus mixed and carried along with the blood through- 
out the system, they act directly on the nervous extremities of the 
internal membrane of the vascular system, and thus excite febrile 
reaction, without the previous establishment and agency of local in- 
flammation.t 

* Journal de Physiologie, 1823. 

t Dr. James Johnson, the very able editor of the Medico-Chirar^ncal Review 
observes — "It has always been our opinion that febrific causes made their first 
impressions on the nervous system; but this, vte tliink, does not disprove that 

absorption first takes place — still less that absorption is not necessary at all " 

Med. Chir. Rev. 



GENERAL PATHOLOGY OF FEVER. 35 

Besides the source of direct vascular irritation already referred 
to, there is another one, perhaps still more common and extensive 
in its influence ; namely, retained recrementitious matter, in conse- 
quence of accidental glandular torpor or inactivity. When an ex- 
cretory organ is impeded in its functions, and ceases to effect a due 
elimination of the recrementitious matter which it is destined to 
cast off", the eff'ete elements must necessarily remain in the blood, 
unless some other organ vicariously supphes the function of the tor-, 
pid emunctory. A source of vascular irritation will thus be created ; 
for it cannot be presumed that recrementitious matter, even in its 
elementary state, can long remain commingled with the blood, in 
inordinate quantity, without giving rise to more or less of morbid 
excitement. "Thus, if from certain causes elements entering into 
the composition of bile, abound in the blood, a source of disorder 
or of irritation is present in the blood. This irritating cause must 
act upon those parts which are sensible to its impressions, and to 
which it is incessantly and immediately applied. Derangement of 
the whole vascular system becomes the consequence of such irrita- 
tion offered to the nerves, ramified upon the heart and blood-vessels, 
but more especially in the organ destined to combine and to secrete 
under new forms, the materials now so abundantly presented to 
it."* Thus, too, if the cutaneous exhalation be arrested in conse- 
quence of the sudden influence of cold, a large portion of the recre- 
mentitious perspirable matter will be retained in the circulation. 
If this be not removed out of the system, by the vicarious action of 
some other organ, the blood will become surcharged with substances, 
which the welfare of the economy requires to be cast off, and which 
must necessarily impart to it a morbific or irritating quality. This 
circumstance, together whh the internal congestions which usually 
attend torpor of the cutaneous exhalents, becomes a direct source of 
irritation to the heart and arteries, and consequently of febrile ex- 
citement. 

With all the evidence which we possess, therefore, that the blood 
frequently becomes charged with substances of an irritating or dele- 
terious character, there can, surely, exist no reasonable doubt, that 
fever is sometimes the result of direct and primary irritation of the 
heart and arteries ; for it will not be denied, that agents which are 
capable of causing morbid impressions on the nerves of the skin, 
the alimentary canal, or of any other organ, will be equally capable 
of producing irritation in the heart and arteries, when brought in 
immediate contact with their internal surface ; and no one, certainly, 
will maintain, that irritating impressions made upon the whole or 
a part of the internal surface of the vascular system, will not be as 
likely to excite that morbid vascular action which constitutes fever, 
as when the irritation is conveyed to this system sympathetically, 
from some remote local inflammation.t 

* London Medical Repository, No. 102, p. 509. 

t [Although Cullen allowed that the flui,ds underwent morbid changes in fe- 
vers, he maintained that they were the co^nsequenc^s, not the cause of disease. 



36 GENERAL PATHOLOGY OF FEVER. 

Evident, therefore, as it unquestionably is, that fever "J^^'^^^j^g 
often does, arise from morbific impressions made primary "^pvhans 
vascular system, it is nevertheless equally manifest, that iVs^P®;";^^' 
still more frequently the result of a ^x\xQ\y sympathetic ww^^^^i^^ 
proceeding from local irritation or inflammation pre-estaDiisnea oy 
the febrific cause. This latter mode of febrile ongui is accordmg 
to some modern pathologists, the only possible way in wliicli levers 
can arise ; as if morbific impressions made directly upon the Diooa- 
vessels, could be less apt to derange their functions than when cow- 
municated to them sympathetically through the medium ot the 
nerves. It is probable, however, that the primary morbid condi- 
tion whence the sympathetic febrile actions emanate, consists much 
more frequently in mere irritation of functional derangement than 
in actual inflammation. I presume that those febrific causes which 
do not make their impressions directly on the lining membrane of 
the heart, arteries, or capillaries, by being admitted into the circula- 
tion, cause, in the first place, irritation and consequent functional 
derangement in one or more important organs or structures of the 
system. In consequence of this local irritation or deranged action, 
the equilibrium of excitement and of the circulation becomes dis- 
turbed, the vital properties deranged, and the sanguiferous system 
is finally brought into a state of febrile reaction. 

Fever, as has already been observed, always, perhaps, commences 
by a local irritation, or morbid excitement. Even when the disease 
results from causes that act immediately on the internal surface of 
the vascular system, the irritation, or primary morbid excitement, 
is probably confined, at first, to a comparatively small portion of this 
system. Every agent, whether morbific or medicinal, appears to 
have a tendency, in its ulterior operation, to affect particular organs 
or structures in preference to others. On whatever part of the sys- 
tem the primary impression is made, the excitement produced is 
chiefly conveyed to some particular organ or part, according to the 
peculiar character of the primary impression. Ergot, whether re- 
ceived into the stomach, or injected into the rectum, produces an 
excitement in the nerves of the part to which it is applied, which is 
especially conveyed to the gravid uterus, and so far as can be per- 
ceived, to no other part. The infusion of jalap, introduced into the 
circulation, will act upon the alimentary canal, and produce purg- 
ing : cantharides, whether taken into the stomach or applied to the 

Of late an attempt has been made to revive the humoral pathology, by a more 
accurate chemical examination of the blood, and by experiments of injecting 
morbid and irritating matters into the circulation. The facts which have been ascer- 
tained certainly show that a morbid state of the blood may perform an important 
part in developing some of the phenomena of fever. But they do not warrant the 
conclusion of some of the European investigators, nor of Dr. Stevens of the West 
Indies, that fever is entirely dependent upon such a cause. The saline treatment 
of Dr. Stevens has not as yet got into credit with the profession ; nor has the prac- 
tice of medicine been at all modified by the recent advance of humoral patho' 
logy. — Mc] 



GENERAL PATHOLOGY OF FEVER. 37 

surface, is apt to inflame the neck of the bladder ; and, in short, the 
influence of almost every agent appears to possess a kind of elective 
aflinity for some particular organ or structure of the organization. 
That this should be the case, might, indeed, be inferred from physio- 
logical principles, independent of the evidence of experience. That 
each organ and structure of the animal system is endowed Avifh a 
pecuhar modification of the vital properties, may be regarded as an 
established fact in physiology. In this principle we may perceive 
the reason why different agents manifest peculiar tendencies to act 
on diflferent parts of the system. Without doubt when an impres- 
sion is made on the system, it will be most felt by that structure 
whose specific or peculiar vital properties are most in relation with 
it. When an impression is made on the nervous extremities of any 
part of the body, the excitement produced is conveyed by the nerves 
to the brain, and from this organ it is reflected or radiated through- 
out the whole nervous system. That this is the ordinary course of 
nervous excitement from impressions made on the sentient extremi- 
ties, will scarcely be disputed by any one who has carefully attended 
to the functions of the brain and its appendages. It is impossible to 
give a rational explanation of many sympathetic phenomena, unless 
we trace the course of nervous excitement from its origin to the 
brain, and thence to the part which manifests the sympathetic ac- 
tion. If, then, each organ and structure of the animal system be 
endowed with its pecuhar modification of excitability,^ we may 
justly presume, that some parts of the organization will be insensi- 
ble, whilst others will be more or less sensible to particular impres- 
sions, and consequently there will be some parts in which a new 
excitement will be produced by the impressions reflected by the 
sensorium commune, whilst, in other organs and structures no im- 
mediate effect will be produced. Thus, if tartar emetic be kept in 
contact with the external region of the stomach, the impression 
which it causes will be conveyed to the brain, which in its turn will 
reflect the impression throughout the whole nervous system; but 
as the stomach alone is endowed with a mode of feeling capable of 
receiving this peculiar impression to a prominent degree, it will be 
in this organ that its effects will be most conspicuous.! 

* The word excitability is here used to express the power of being excited into 
action, and includes both sensibility and contractility. 

t The author of a Review of the first edition of this work, doubts the correct- 
ness of this assertion. It must be admitted, that tartar emetic, when applied to 
the external surface, very rarely produces either nausea or vomiting. I have, 
nevertheless, met with one remarkable instance of this kind. At three different 
periods a solution of this article was applied to the epigastrium, and at each 
time he experienced very distressing and protracted nausea. The general fact, 
however, which it is intended to illustrate by the above observation, cannot be 
disputed. It is well known, as has been observed in the preceding page, that 
to whatever part remedial substances are applied, they manifest the same ten- 
dency to act on particular organs or structures, as if they were taken into tlie 
stomach. I have known tobacco applied to the feet to give rise to nausea and 



38 GENERAL PATHOLOGY OF FEVER. 

Let us suppose, then, that a febrific agent acts primarily upon 
the nerves of the stomach or of the sidii, or of any other part oi tne 
body. The impression produced, will be conveyed to the senso- 
rium commune, whence it will be reflected througliout tlie whole 
nervous system. But as the various organs and structures ot the 
system are endowed, each with its own peculiar modification ot 
the vital properties, some may be insensible, whilst others, perhaps, 
are peculiarly susceptible of receiving and responding to the re- 
flected morbific impression ; and these, it may be reasonably pre- 
sumed, \vill be irritated and functionally deranged, before the other 
organs or structures become afiected. From the part thus primarily 
irritated, the morbid excitement passes from organ to organ, or 
tissue to tissue, according to their various sympathetic relations 
with each other, and with the part primarily afiected, until the 
whole system becomes morbidly excited. 

It is extremely improbable that the morbid excitement or impres- 
sion caused by a febrific agent, can ever bring every part of the 
system, simultaneously, or pari passu, into a state of morbid action. 
The direct influence of the remote or exciting causes of fever, do 
not, probably, extend beyond the simple impression which they 
make on the sentient extremities. Every subsequent morbid change 
in the development of fever, must depend wholly on the relative 
affinities of the various structures with each other, and with the cha- 
racter of the primary impression ; and, from what has been said 
above, it can scarcely be doubted, that the primary impression or 
nervous derangement, resulting directly from the action of the mor- 
bific cause, always terminates in the production of prominent mor- 
bid excitement in some particular organ or structure, preliminary to 
the actual development of the general febrile vascular reaction. 

That the primary morbific impressions are, however, almost uni- 
versally directed upon the mucous membrane of the alimentary 
canal, as is asserted by Broussais, appears to be as far from truth, 
as that all fevers are purely symptomatic. Almost every organ or 
structure of the system may, without doubt, be the first to suffer 
functional derangement or irritation from external morbific im- 
pressions. The lungs, the liver, the brain, or the skin, &c., some- 
times receive the reflected impressions, and become the primary 
focus whence the febrile actions emanate. Observation, moreover, 
discountenances the opinion that the primary local derangement 
thus produced, amounts often to the grade of inflammation. De- 
ranged or irritated excitement of an organ or structure, may be ade- 
quate to set on foot a train of morbid changes which will ultimately 
terminate in febrile reaction. A draught of cold water, while the 
body is in a state of free perspiration, may, in its ultimate conse- 
quences, establish fever. In this case the impressions of the cold 
Avater on the nerves of the stomach, are transmitted through the 

vomiting, and every physician must have observed similar facts. [I have repeat- 
edly observed this fact, tartar emetic plasters occasionally produce severe vomitin<' 
in irritable patients. — Mc] 



GENERAL PATHOLOGY OF FEVER. 39 

medium of the sensorium commune, to the cutaneous exhalents and 
capillaries. A state of torpor and functional derangement of these 
vessels, together with the deranged sensibility of the cutaneous 
nerves, immediately ensues, and the patient experiences a sense of 
chilliness, with more or less constriction of the extreme vessels. 
These, then, are the first sympathetic phenomena arising from the 
influence of the remote or exciting cause ; and from these morbid 
changes, others proceed in regular sequence until the fever is fully 
developed. Thus, from the torpor of the exhalents and diminished 
circulation in the external capillaries, three pathological conditions 
necessarily arise, which tend especially to excite febrile reaction. 
In the first place, a large portion of recrementitious perspirable mat- 
ter will be retained, in the circulation ; secondly, the retreat of the 
blood from the extreme vessels will cause it to accumulate in the 
heart and large internal vessels; and thirdly, the action of the liver* 
and other internal organs, will be more deranged in consequence of 
their direct sympathetic relations with the cutaneous exhalents. 

But although the organs which sustain the primary irritation — 
and from which the morbid febrile changes are diffused throughout 
the system, as from a centre, are not, perhaps, at first in a state of 
actual inflammation, yet, as they are already morbidly irritable and 
irritated, they will be especially apt to pass into a state of complete 
inflammation soon after the febrile reaction is established, and an 
increased momentum given to the blood. It may be observed, too, 
that when a morbific cause acts directly on the stomach, as in the 
example just assumed, the fever will be apt to become early com- 
plicated with conspicuous irritation or inflammation of the mucous 
membrane of this organ ; in consequence of having sustained the 
direct injurious impressions of the remote cause, and consequently, 
being, from the very onset of the disease, in a morbid condition. 

It must be remembered that inflammation consists not only in 
congestion of the inflamed capillaries, but also in an altered or mor- 
bid condition of their vital properties: and hence, when an organ is 
already in a state of morbid excitement or irritation, inflammation 
will very readily ensue, when, by a general increased momentum 
of the circulation, the blood is urged into the debilitated and morbid 
capfllaries. It is on this account that we so often find inflammation 
supervening in the stomach and intestinal canal in fevers. The 
mucous membrane of these organs being so much exposed to the 
action of irritating causes, is far more frequently the seat of irrita- 
tion than any other structure of the system, and it is almost invari- 
ably in a more or less deranged condition in all general diseases. 
This being the case, it is evident that this structure must be especially 
liable to secondary inflammation in febrile aflections ; and this, in fact, 
is fully confirmed by experience. 

Inequilibrium of the circulation and excitement, is one of the 

* Vide Johnson on the Diseases of Tropical Climates. Of the correctness of 
his sentiments, concerning the influence of what he calls the cutaneo-hepatic 
sympathy, I entertain no doubt. 



40 GENERAL PATHOLOGY OF FEVER. 

most important characteristics of fever. Although fever is empha- 
ticallv a general malady, and a morbidly excited condition, it musi 
not be supposed, that every sensible and irritable structure, tnou^n 
functionallv deranged, is in a state of increased excitement, wniie 
the heart and arteries are energetic, and morbidly active, the mus- 
cular system is usually languid and enfeebled. An mcreasea ac- 
tivity of the intestinal capillaries and exhalents may be attenaea 
with diminished activity of the capillaries and exhalents ol the 
external surface. Inordinate action of the kidneys is often accom- 
panied with torpor of the liver, and always with torpor of the 
cutaneous exhalents. Sometimes the capillary system is inordi- 
nately active, whilst the heart and arteries manifest but little or no 
increase of excitement ; and occasionally the brain and nerves are in 
a state of great activity, with very feeble reaction of the heart and 
arteries. The same observations apply to the distribution of the 
blood. Whilst it is morbidly deficient in some organs, it will be 
excessively abundant in others ; whilst the capillaries of one struc- 
ture or organ are engorged and inflamed, those of other parts will 
be devoid of the regular portion of the circulating fluid. These facts 
have a most important bearing on practice ; for they point directly 
to the fundamental principle of treatment — namely, to excite and 
invigorate those organs that are torpid, at the same time that we 
depress and debilitate those that are morbidly active. 

It has been supposed that febrile excitement, or the essential mor- 
bid action of fever, is always the same ; and that the various modi- 
fications which this form of disease is known to assume, depend 
wholly upon the local irritation or inflammation which may occur, 
or rather the organ or structure which may be its seat. To a certain 
extent, this opinion appears to be well founded. It is very evident, 
for instance, that in proportion as the brain and nerves become 
affected, so will the fever acquire a low or typhoid grade in its general 
character. Of two individuals seized with fever from the influence 
of atmospheric vicissitude, one will, perhaps, be affected with a low 
or typhoid form of fever, whilst, in the other, the fever will assume 
a high grade of inflammatory or synochal reaction. In the former, 
prominent symptoms of severe nervous disorder will attend ; and 
if the disease be violent, decided manifestations of cerebral inflam- 
mation will probably occur. In the latter case, little or no prominent 
signs of cerebral disturbance or irritation will ensue ; but instead of 
this, symptoms of local inflammation in the fibrous or serous struc- 
tures, or in one or more of the abdominal organs, will probably be 
observed. • 

That the occurrence of irritation or inflammation of the brain 
should impart a low and typhoid character to fever, and thus give 
to it a pecuUar aspect, is by no means difficult to comprehend ; for 
it is manifest, that when the fountain of the vital energies the brain 
is prominently deranged, all the powers of life, however excited' 
must languish and sink. This subject will, however, be more par- 
ticularly discussed under the head of continued fever, being referred. 
to at present merely for the purpose of directing the reader's attention 



GENERAL PATHOLOGY OF FEVER. 41 

to the general fact, that fevers, arising from the same cause, and 
essentially identical, receive important modifications from the seat 
and grade of the local affections which may supervene. 

The mode in which the occurrence of local inflammation may be 
favoured daring the progress of fever, has already been mentioned. 
Besides the peculiar influence of the remote causes, in deranging 
particular organs or structures, in preference to others, and thus laying 
the foundation for local inflammation, there are, however, other cir- 
cumstances which are, perhaps, still more commonly concerned in 
favouring the supervention of inflammation, and inviting it to par- 
ticular organs. The human system is rarely found in so perfect a 
state of health, as that some of its various organs or structures are 
not more or less debilitated or disturbed. The multifarious influ- 
ences that are continually operating on the animal economy, do not 
suffer the vital machine to go on without some, though often imper- 
ceptible, derangement in one or more of its various organs. Add to 
this, the congenital debility of some structures, and the constitutional 
prepotency of others, and we have a sufficient number of latent 
causes, (varying in different individuals, and in relation to some, in 
the same individuals at different periods,) to determine the occurrence 
of local inflammation, when the nervous and vascular systems are 
thrown into a state of tumultuous excitement. 

Much variation occurs in different cases, as to the period after the 
commencement of the febrile changes, when local inflammations of 
this kind supervene. If any organ or structure happen to be espe- 
cially predisposed to inflammatory excitement, or when the exciting 
cause is of such a nature as to act with great force upon some organ 
or structure, inflammation may commence with the onset of the 
febrile vascular reaction. More commonly, however, the local 
inflammation does not supervene until several days after the com- 
mencement of the fever ; and in many instances, not until the latter 
period of the disease. The occurrence of local inflammation in general 
fevers, of course, always greatly increases the obstinacy and danger 
of the disease ; and this is pre-eminently the case, when such inflam- 
mations supervene in fevers of typhoid character. 

Prone, as febrile affections unquestionably are, to give rise to 
secondary inflammations, many instances occur which remain en- 
tirely free from inflammation throughout the whole course of the 
malady, although irregular determinations and inequilibrium of 
excitement appear to be inseparably connected with this form of 
general disease. 

It has been observed above, that fevers, essentially identical in. 
the nature of the general febrile excitement, often assume prominent 
modifications, apparently radically diverse from each other, in con- 
sequence, solely, of the different organs or structures which happen 
to sustain the principal force of the malady. From this unquestionable 
fact some pathologists have inferred that there can be fundamental 
and specific diversities of fever, presuming that the general febrile 
excitement is always essentially the same ; and that all the diversities 
which occur in the course and phenomena of this mode of disease, 



42 GENERAL PATHOLOGY OF FEVER. 

are invariably the result of the diverse local affections that may 
accompany the malady. It appears to me, however, that the J^<^^ur- 
rence of original and specific diversities in the nature ot ^eorue 
excitement, is susceptible of very plausible, and, to me at least, sum- 
ciently satisfactory illustration. It is impossible to conceive why the 
capillary system of blood-vessels, in which doubtless all the essential 
febrile actions reside, should not be as susceptible of radical diversities 
of excitement as the nervous system itself. Upon this point we may 
be allowed to refer to the exanthematous affections ; for, whatever 
Broussais and his followers may say to the contrary, some of these 
diseases are, at least in the first stage, simply febrile, without local 
inflammation. In the general phenomena of the fever of distinct 
small-pox, during the first day of its course, there is nothing that is 
different from an ordinary synochus, and yet no one can for a 
moment seriously doubt, that the essential morbid excitement of the 
extreme vessels in this affection, is specifically distinct from that of all 
other febrile diseases. It is true that this disease is produced by a 
specific cause ; but the morbific impressions made by malaria, are 
probably as distinct from those of cold, as the impressions of small- 
pox virus are from those of either of them. No one has ever observed 
yellow fever or the plague to arise from atmospheric vicissitudes; 
and malaria by itself has, I presume, never been known to give rise 
to inflammatory rheumatism, or to simple catarrhal fever. If, then, 
in relation to the exanthemata, general febrile excitement is unques- 
tionably susceptible of radical and specific peculiarities, the possi- 
bility of such fundamental diversities, in the nature of the morbid 
excitement of fever, independent of accidental local affections, must 
be admitted, even in the general favers, usually denominated idio- 
pathic. It is probable, that koino-miasm.ata,idio-m.iasmata,?ixA 
cold, or atmospheric vicissitudes, produce each its peculiar mode of 
morbid excitement; for, although the general and obvious febrile 
actions, and even the accompanying local affections which they 
respectively produce, may not be perceptibly diverse, yet, it may be 
presumed, the fundamental morbid condition or excitement of the 
nervous and capillary systems, upon which the febrile phenomena 
depend, is in each variety of fever, radically distinct, or sui generis. 
So far, however, as the fevers occasioned by one or the other of these 
remote cases, difler in form and general character from each other— 
as, for instance, the various forms of miasmal fevers— it can scarcely be 
doubted, that the most common source of these diversities consists in 
the accidental local affections which occur, or the character of the 
structure most prominently deranged, or the greater or less intensity 
of the operation of the remote cause. 



CAUSES OF FEVER. 43 

CHAPTER II. 

OF THE CAUSES OF FEVER. 

The causes of fever are generally divided by pathologists into two 
varieties, the predisposing and the exciting. The former are all 
those external and internal causes which tend to lessen the power of 
vital resistance to the influence of morbific agents. The latter are 
those causes which excite actual disease by the deleterious or irritating 
impressions which they make on the animal system. There exists, 
however, no absolute difference in the nature or character of these 
two varieties of morbific causes. The same agent, or circumstance, 
may manifest its influence on the animal economy, either as a pre- 
disposing or an exciting cause of fever, according to the degree of 
intensity with which it acts, or the previous condition of the system. 

Sect. I. Of Predisposition, and Predisposing Causes. 

When, either from a general condition of the organization, or some 
local, functional or organic defect, the animal economy is especially 
susceptible of the influence of morbific causes, a predisposition to 
disease is said to exist; and this predisposing condition may be either 
natural, or accidental, or hereditary. 

As the human system is continually under the influence of causes 
which have a tendency to interrupt and terminate its actions, life 
would be but ephemeral in its duration, and harassed by constant 
disease, if the animal organization were not endowed with the inhe- 
rent power of resisting, to a degree, the influence of injurious causes. 
It is by the aid of this vital resistance, that man is enabled to live 
through a long series of years, amidst a multiplicity of causes, which 
conspire unceasingly to his destruction. In relation to the degree in 
which this power of resisting injurious influences is possessed by dif- 
ferent individuals, there exists great diversity : and hence the various 
degrees of constitutional or natural predisposition to fever, which ob- 
tain among different individuals. Thus, the prick of a needle will, 
in one individual, cause great pani and constitutional irritation ; in 
another, syncope ; in a third, convulsions or tetanus ; and in a fourth, 
scarcely any perceptible consequences at all.* There exists, there- 
fore, a natural or constitutional predisposition to disease in some 
individuals, wholly independent of accidental causes or mere casual 
debility ; and this constitutional aptitude to disease depends, proba- 
bly, on the peculiar organization of the animal system. 

Under the head of natural, or constitutional predispositions, must 
be ranked those specific predispositions which render the system 
susceptible of certain specific diseases, and which are wholly lost by 

* Sur le differens de Degrees de Resistance vitale dans les JMaladies, &c. Par 
M. L. Martinet, M.D.—Revuie Medkale, Oct. 1824. 



44 CAUSES OF FEVER. 

the actual occurrence of these maladies. These specific P^^'.^jP^" 
sitions are especially incomprehensible and mysterious, 
temperament, nor constitutional vigour, nor debility, nor c y - 
cumstance connected wiih the health of the individual, appears lo 
have any relation with, or influence upon them. 

With regard to accidental, or acquired predisposition, observa- 
tion has not left us so entirely in the dark. According to tne late 
Dr. Rush, general or local debility, accompanied by an increased 
excitability, constitutes the state of predisposition to tever. vvitnout 
doubt, general debility, with increased excitability, must render the 
system more liable to the action of irritating or exciting causes; yet 
it does not appear that this condition of the system can, with pro- 
priety, be considered as constituting the essential state of the organi- 
zation which predisposes to fever. It is well known that the most 
robust and healthy individuals are generally the first and most certain 
victims of febrile epidemics. The vigorous and healthy are often 
prostrated under the devastating dominion of pestilence, and even 
under the less ruthless sway of the milder paludal fevers, whilst the 
feeble and the valetudinarian pass along untouched. It may, more- 
over, be observed, that in the feebleness of convalescence from bilious, 
typhus, and other forms of fever, fresh attacks, or relapses, are by no 
means so common as one would expect, if mere debility constituted 
febrile predisposition. When we wish to obviate fever, after a sur- 
gical operation, we reduce the system by a low diet, purgation, and 
perhaps blood-letting.* 

In a general way, every cause, capable of deranging the health of 
the animal economy, may, when acting with moderate force, produce 
such a change in one or more organs, as will predispose the system 
to fever, requiring only some further exciting cause to evolve actual 
febrile disease. Predisposition, produced by the influence of acci- 
dental causes, consists, probably, always in more or less functional 
derangement of one, or, at most, a few structures or organs, or in a 
disturbance of the healthy balance of excitement and the circulation. 
I have already stated some reasons which render it highly probable 
that the impressions of every morbific cause, on whatever part of the 
system primarily made, is, in the first place, reflected upon some par- 
ticular organ, according to the nature of the impression, and the 
organic sensibility of the various parts of the system. If this be cor- 
rect, it is manifest, that if the morbific impression, thus reflected upon 
an organ or structure, be too weak to establish a sufficient degree of 
irritation to excite general derangement, or febrile reaction, the result 
will be only a slight degree of insulated functional derangement, or 
irritation, which, though not manifested by any feelings or appear- 
ances of ill health, is still an incipient link of disease, and wants only 
some additional morbific influences to enable it to put in motion the 
latent train of morbid sympathies. How greatly mere functional 
derangement of an important organ aids the cause of fever in deve- 
loping diseases, is often conspicuously illustrated by the influence of 

* Richter's Specielle Therapie, vol. i. p. 3G. 



CAUSES OF FEVER. 45 

digestive derangement in the production of fever. Let but this citadel 
of the animal system languish, and the enemies of human health will 
speedily attack the outposts, and make an easy conquest of the whole. 
Hence, of all the precautions which those who visit insalubrious 
climates may be required to adopt, the avoidance of every thing 
which is calculated to derange the digestive functions, is perhaps the 
most important. 

By a well-known law of the animal economy, every agent, how- 
ever deleterious, gradually diminishes, and finally almost destroys 
the susceptibility of the system to its influence, by long-continued or 
very repeated action. Hence, every agent will, caeteris paribus, 
manifest its operation with a promptitude and intensity, proportion- 
ate to the degree of previous immunity from its influence. It is this 
circumstance which causes the difference of predisposition to endemial 
fevers, between the acclimated natives of insalubrious regions, and 
strangers arriving from northern latitudes. This variety of predis- 
position depends in no degree on a want of constitutional vigour or 
general health. The robust and healthy are, in general, as much, if 
not more, under its influence, than the weak and infirm. By a gradual 
or protracted exposure to morbific agents, the animal economy loses, 
insensibly, its natural susceptibility to their influence. When such a 
change is effected by the combined operation of climate and endemial 
morbific agents, the system is said to be acclimated or seasoned, and 
the individual, thus seasoned, enjoys a comparative immunity from 
the diseases of the climate. 

Besides the foregoing source of predisposition to disease, from 
causes peculiar to hot climates, there is another and perhaps not less 
powerful one — namely, atmospheric heat. High atmospheric tem- 
perature is, strictly speaking, rather a predisposing than a morbific 
agent in relation to its influence on the human system.* In this re- 
spect it exercises a very powerful influence in the production of 
diseases. Long-continued exposure to an elevated degree of solar 
heat, tends, very considerably, to increase the general irritability of 
the system, and to lessen the power of vital resistance. Hence, the 
frequency of tetanus in hot climates, from injuries, or from the influ- 
ence of the cool and damp night air; and hence, too, the greater lia- 
bility to this and other irritative affections, during the hot seasons of 
our own climate, than in the cold months. Atmospheric heat tends, 
moreover, to predispose to fever, and other affections, by the profuse 
and continued perspiration it causes, as well as the redundant secre- 
tion of bile it is apt to excite. By these over-excited actions of two 
important organs, the general system is exhausted, whilst the organs 
themselves are rendered more susceptible to the injurious impressions 
of one of the most common and powerful exciting causes of disease — 
namely, cold. 

In relation to those predispositions to disease which are transmit- 
ted from parent to offspring, it may be sufficient to observe, in this 
place, that they depend, no doubt, on a peculiar physical condition or 

* Dr. James Johnson on Tropical Climates, &c. 



46 CAUSES OP FEVER. 

intimate state of the organization, which we may P^"^^""^f ' Jf ^f tfe 
to be imparted by the parent to the offspring, as the conio 
cbuntenance, or of the general structure of the body- 

Sect. II. Of the sources of Morbific Causes, and their general 

character. 
When we take a general survey of the source of all the possible 
causes of disease, we find that in relation to their origin, they range 
themselves under the following four general heads, viz : 

I. Recrementitious substances, which, in health, are separated 
and thrown out of the system, but being retained m the cir- 
culation, or reabsorbed, become a source of irritation to the 
sanguiferous system, and, therefore of^ irritative diseases. 
These morbific causes are always secondary, being, them- 
selves, the consequences of an anterior injurious cause or 
impression. Thus the retention of the perspirable matter can 
occur only in consequence of the influence of some previous 
cause, adequate to disturb or arrest the action of the cutane- 
ous exhalents. The recrementitious fluids, which appear to 
be most injurious to the animal economy, when retained iti 
the circulation, even in their elementary forms, are the per- 
spirable matter, the bile, and the urine ; and of these the first 
is, perhaps, the most frequently concerned in the production 
of disease. The influence of causes of this kind in the de- 
velopment of disease, is, probably, much more extensive than 
is generally admitted in etiological inquiries. In all that 
extensive class of febrile affections which arise from the influ- 
ence of cold, retained perspirable matter performs, probably, 
a principal part in the development of the irritative vascular 
excitement. 
Checked perspiration, or, more correctly speaking, inactivity of the 
cutaneous exhalents, constitutes the initial link in, perhaps, three- 
fourths of our febrile diseases. Let it not be imagined, that, as the 
recrementitious substances which are retained in the circulation are 
in a simple or elementary state, they cannot possess powers sufficient- 
ly irritating or active to excite morbid vascular action. In whatever 
form these substances may exist in the blood, they are still recremen- 
titious, and it is not to be presumed, that materials of this character 
could be long retained without an injurious influence on the animal 
economy. Accidental torpor of one emunctory is often vicariously 
supplied, by increased activity of another, and disease thus prevented. 
Thus if, after the cutaneous exhalents have been rendered torpid 
by a sudden influence of cold, the flow of urine becomes unusu- 
ally copious, disease will rarely ensue. Indeed, the all-wise and 
BENEVOLENT Creator has provided against the injurious conse- 
quences which must otherwise have resulted from the constant 
changes to which the function of the skin is necessarily exposed by 

* Richter's Specielle Therapie, vol. i. 



CAUSES OP FEVER. 47 

placing in the interior an organ whose functions may, in a great de- 
gree, supply any accidental deficiency in the action of the fornaer. 
II. Irritating substances generated within the body, but wholly 
independent of any organic actions. These causes of dis- 
ease are usually generated in the primae vias, and consist of 
worms, acids, mucus, and various other irritating substances, 
resulting from the fermentative or putrefactive processes. 
Worms have been, and by some are still considered as innocent 
inmates of the human body. This, however, is most certainly an 
erroneous sentiment. Without doubt, a few, or even a considerable 
number of worms lodged in the alimentary canal, may not be able 
to disturb the general system, when in a state of good health and con- 
stitutional vigour; but when the body is debilitated and irritable, as 
it commonly is during the period of dentition, the presence of worms 
in the intestinal tube will frequently give rise to the most alarming 
affections. Worms tend, moreover, to sustain and protract fevers 
produced by other exciting causes; an inattention to which fre- 
quently renders the progress of ordinary diseases peculiarly perplex- 
ing and unmanageable. It is not uncommon to meet with cases of 
slight febrile disease in children, from cold, which continue in spite 
of appropriate remediate efforts, gradually assuming the form of slow 
remitting fever, with a foul tongue, and gastric disturbances, and at 
last suddenly assume a favourable aspect, on the expulsion of a few 
large lumbrici. 

The agency of causes of this kind in the production o^ fever, was, 
however, formerly considered nmch more extensive than it appears, 
in reality, to be. Verminous epidemic fevers are described by some 
of the older writers, and saburral fevers were supposed, as it would 
appear, very common. Without ascribing so great an importance to 
these causes, as originators of fever, it is nevertheless unquestion- 
able that they do at times give rise to febrile affections, independent 
of all other morbific irritants. Their febrific tendency is, however, 
much more frequently mnnifested in the support, or additional vio- 
lence which they give to fevers arising from other causes, than in ori- 
ginating febrile affections by their own immediate influence. 

III. Morbific agents, generated out of the animal body, consist- 
ing either of deleterious substances floating in the air, or of 
the sensible properties of the atmosphere, or finally mecha- 
nical causes — namely: miasmata, noxious gases, heat, cold, 
electricity, humidity, and mechanical injuries, &c. 

IV. The fourth and last class of morbific agents comprehends 
those which are generated by morbid organic actions of the 
living system, constituting the various contagions. 

The principal causes, embraced under the last two heads, are so 
extensive in their influence on the human system, and so interesting 
and important, both in a medical and scientific point of view, that a 
separate and full exposition of their respective modes of origin, and 
physical, as well as morbific characters, will not be deemed inappro- 
priate in a work of this kind. 



48 CAUSES OF FEVER. 



Sect. III. Atmospheric Temperature, and its relations with the 

Animal Syste77i. 

A certain quantity of heat is indispensable to life, throughout the 
whole range of organized beings. Every animated being possesses 
an inherent power to generate heat, and to resist, to a certain extent, 
the physical law of the distribution of heat ; and, consequently, to 
maintain its peculiar or specific temperature, when placed in a me- 
dium either many degrees below or above its own temperature. The 
constant and rapid reproduction of heat by the vital powers, keeps up 
the natural temperature of the animal body although surrounded by 
a medium which abstracts its heat, with great rapidity. Such, in- 
deed, is the evolution of heat by the human body, that an atmosphere 
of the temperature of 98° is generally oppressive and unpleasant by 
the feeling of warmth which it causes, although at this temperature 
of the air, no heat can be communicated by the surrounding atmo 
sphere to the body. The temperature most grateful and invigorating 
to the human system, ranges from about 60° to 65°. " This tempera- 
ture of the air appears to abstract the heat of the body in about the 
same proportion in which it is generated in the healthy slate of the 
system ; and this degree of the temperature is, therefore, the most 
congenial, for it neither exhausts the vital powers, nor gives rise to 
unpleasant sensations." 

There exists, however, considerable diversity in the human consti- 
tution, in relation to the power of supporting the extremes of tem- 
perature. This depends not only on the original vigour of the system, 
but also, greatly, on the influence of habit and modes of living. A 
person endowed with a vigorous constitution, and with habitual good 
health, will bear a degree of cold without any unpleasant feelings, 
which, to one of a feeble and exhausted system, will be a source of 
painful sensations and indisposition. Habit, in relation to previous 
exposure, has a powerful influence in varying the efiects of tempera- 
ture on the animal system. The same temperature will cause feel- 
ings of severe cold or great warmth, according as the body has been 
previously exposed to a high or low temperature. Whenever the 
surrounding medium abstracts the heat of the body more rapidly than 
it is generated by the regular actions of the animal economy, the 
sensation of cold will be produced ; and the intensity of. this sensa- 
tion will always be proportionate to the rapidity with which the heat 
is abstracted, and the feebleness of the heat-generating power of the 
system. 

I. Physiological effects of cold.— When the temperature to which 
the human system is exposed, is so low as to give rise to the sensation 
of cold, its immediate etfects are : l. Diminution of the action of 
the cutaneous exhalents, and of the external capillary blood-vessels, 
giving rise to a pale, shrunken, and dry state of the skin ; 2. Dimi- 
nished action of the heart and arteries— manifested by'sniallness, 
weakness, and slowness of the pulse. In relation to the effects of 
low temperature on the frequency of the pulse, however, there ex- 



CAUSES OF FEVER. 49 

ists some discrepancy of opinion among physiologists. From the 
experiments of Drs. Stock, Spooner and M'Donnel, it would seem, 
that although the strength and size of the pulse are diminished by cold, 
yet its frequency is considerably increased. Against these experi- 
ments we may oppose those performed by Currie, Rush and Klapp ;* 
and in my own experiments I have invariably found the pulse dimi- 
nished, both in frequency and in volume, when cold was applied to 
any particular portion of the body.t 3. Diminished sensibility of 
the external parts, passing by degrees throughout the whole system. 
Hence the benumbed state of hands, fingers, and other external parts, 
the torpor of the sensorial functions, and the sluggishness and feeble- 
ness of muscular action which occur from the protracted influence of 
severe cold ; and in this way, too, an almost irresistible inclination to 
sleep occurs when the cold is very intense. Artificial somnolency has 
been produced in certain animals by exposing them to a very low 
degree of temperature. 4. When moderately applied, cold encrease* 
the powers of the digestive organs. Hence the aphorism of Hippo- 
crates, Hieme ventres calidorus sunt. The appetite increases, and 
the process of digestion is performed more rapidly in moderately cold 
and dry than in warm weather. We are informed by Xenophon, 
that the Greek soldiers, on their return from Asia, were exceedingly 
harassed by the most severe sensations of hunger, while passing the 
snow-covered mountains of Armenia, although they were allowed 
their ordinary rations of food. When cold becomes very intense and 
protracted, however, the digestive as well as all the other organs of 
the system become enfeebled and inactive. 5, The sudden applica- 
tion of cold causes a hurried, irregular and imperfect action of the 
respiratory apparatus ; and when intense, it checks or impedes the 
efforts to dilate the chest, and these effects mcreose, pari passu, with 
the increased influence of the cold, until at length respiration is per- 
formed so imperfectly as to prevent the due decarbonization of the 
blood, and the whole organization sinks into a state of torpor and 
insensibility. 6. Moderate cold is favourable to nutrition. " ]Man 
and all animals are fatter in winter than in summer ; and in the north 
than in the south." When, however, the cold is applied in an intense 
grade and prolonged in its influence, the process of nutrition is dis- 
turbed and interrupted. 7. The pulmonary exhalation, and the se- 

* That Dr. Stock and the other experimenters observed what they record upon 
this point, cannot be doubted. We can readily admit that when the body is sud- 
denly plunged into cold water, the mode adopted by them, the pulse will at first 
be accelerated. It must be observed that when the body is suddmly immersed in 
cold water, the blood is violently driven in upon the heart and larger vessels, and 
the respiration is performed in a hurried and imperfect manner, in consequence 
of which, the heart is excited into a temporary exertion to overcome the load 
which oppresses it, and the pulse consequently at first accelerated. 

t The pulse of the inhabitants of northern climates is habitually slower than 
the ordinary standard of frequency in the middle latitudes. Amongst the Green- 
landers, it is by no means uncommon to find the pulse as slow as 40 and 45 in a 
minute. — Bcaupre on the Effects and Properties of Cold, p. 50. 
VOL. I. — 4 



50 CAUSES OF FEVER. 

cretion of urine are increased by cold, and supply, in a degree, 
checked exhalation by the skin from the same cause. 

Stri7igxmtur tubuli pcllis, co^mtur ct intus 

Tott variis pellenda viis cxa'cto, ^c. 
8. Cold, when prolonged in its influence, diminishes the venereal pro- 
pensity, (Montesquieu, Esp. des Loix, b. 14, c. 2,) but it does not 
appear to repress the function of generation ; for although the vene- 
real appetite be less constant and urgent in cold than in warm chmates, 
yet the power of procreation would seem to be even greater in the 
former than in the latter. " In Sweden it is not uncommon to see 
women have twenty or thirty children ; and in Russia marriages are 
followed by a numerous progeny."* 9. Cold retards the develop- 
ment of the sexual organs, and the period of pubescence, more espe- 
cially in the female sex. In northern latitudes the catamenia rarely 
commence before the sixteenth or seventeenth year, whereas in the 
ardent climates of the intertropical countries, the menstrual evacua- 
tion is apt to make its appearance as early as the twelfth, and not 
unfrequently as early as the tenth year of age. 

Cold is, therefore, a sedative agent; for, although, when moderately 
and transiently applied, it is generally followed by phenomena at- 
tributable to a stimulating influence; yet these are not, strictly speak- 
ing, the immediate consequences of the low temperature, but rather 
of the reaction of the vital ener^ies^ after the temporary reduction 
of their activity by the cold. When an agreeable glow, and aug- 
mentation of the general vigour are experienced after leaving a cold 
bath, they arise, probably, not from the direct stimulus of the cold, but 
from its having depressed the excitement of the surface, and increased 
the susceptibility to the action of stimuli; in consequence of which 
the ordinary influence of the atmosphere, the warmth of the clothing, 
and even the stimulus of the blood, as well as exercise, and other 
usual exciting influences, will cause an increased degree of excite- 
ment, more especially in the cutaneous capillary system. That the 
phenomena of increased activity and vigour, which sometimes ensue, 
are solely the consequence of a reaction in the system, after the cold 
has temporarily diminished the excitement, and thereby increased the 
susceptibility to subsequent excitation, is fully demonstrated by the 
fact, that unless the system be endowed with a considerable degree 
of energy and activity, no such favourable eff'ects will follow the 
application of cold. If cold produced these effects by its stimulating 
powers, it would, one may reasonably believe, produce them when 
the system is in a state of feebleness; because mere weakness can 

* Beaupre on the Effects of Cold, &c., p. 18. '' In the coldest regions, approach- 
ing the poles^ excessive cold retards the generative flame, and, we may say ex- 
tinguishes the lamp of physical love. Beyond the 65th degree of latitude popu- 
lation continues to decrease, and ends at Spitzbergen and Nova-Zembla. Lapland 
and Iceland females are said to menstruate but little ; they are apathetic in love 
and know but little of the bitter feelings of jealousy, or the vehemence of sexual 
attachment." 



CAUSES OF FEVER. 51 

never annul the operation of a stimulus, provided the excitability be 
not exhausted. That cold must necessarily diminish the actions of 
the system, is evident from its being, in fact, nothing else than a com- 
paratively diminished grade of temperature. For if heat be a stimu- 
his, it is manifest that this stimulus must be lessened in its powers, 
just in the ratio in which its intensity is decreased. Thus, if 80° 
produce a certain degree of excitation, 60° {casleris paribus) must 
produce a less degree and 40° still less, and so on. Correctly speak- 
ing, every agent capable of affecting the animal economy, is a siimu- 
lus; but when we speak of cold and its effects, it is to be always 
understood in a relative sense; for when it is said that cold is a seda- 
tive, it can mean nothing else than that it is less stimulating than a 
higher degree of temperature. 

It is to be observed, however, that although cold unquestionably 
tends to diminish the actions of the system, yet, when applied sud- 
denly, it often manifests a very conspicuous exciting agency on the 
nervous or sensitive system. Thus, a few drops of cold water sprin- 
kled on the face of a person in a state of syncope, or approaching to 
this state, will generally produce immediate excitation and return of 
consciousness. In asphyxia from carbonic acid, or electricity, too. 
cold water dashed on the face and breast, often causes immediate re- 
spiration, and other manifestations of returning life. In cases of this 
kind, the sudden sensation which the cold produces, acts, probably, 
as the exciting cause. 

2. Cold as a morbific agent. — Cold is, perhaps, the most common 
and frequent of all the remote causes of disease in the temperate 
latitudes. Its injurious tendency appears to be much enhanced by 
being conjoined with humidity ; for, a very d?y and cold, air is far 
less capable of abstracting the animal temperature than low tempe- 
rature united with humidity. But the most important circumstances 
Avhich render the impressions of low temperature prejudicial to the 
animal economy, relate to the previous condition of the system itself, 
with regard to the cutaneous transpiration, and antecedent exposure 
to high temperature. The morbific influence of cold is always 
efficient in proportion as the body has been previously exposed to 
an elevated temperature ; and, more especially, in proportion as the 
perspiration is more or less copious. The most powerful of all the 
predisposing conditions of the animal system to the injurious effects 
of cold, is a state of free perspiration, from fatiguing and exhausting 
exercise or labour, under the influence of high solar heat. In this 
state of the body, and scarcely in any other, the sudden application 
of cold to a large extent of the surface, or to the stomacli, in the 
form of ice or cold water, will often suddenly produce the most 
alarming, and even fatal, consequences,* When the animal tempe- 
rature is not rapidly carried off by free perspiration, and the system 
not debilitated by fatigue, cold can never give rise to such sudden, 
violent, and dangerous consequences. The effects here alluded to, 
as resulting from the impressions of cold, while the body is in a state 

* Rush's Medical Inquiries. Currie's Medical Reports. 



52 CAUSES OP FEVER. 

of free perspiration, from fatiguing exercise and atmospheric ? 

appear to be of a nervous or spasmodic character, consistn)g g - 
rally in sudden prostration and effacement of the vital energies oi me 
system. As a febri/ic cause, cold plays a very important part in me 
production of disease. It is not, however, merely as cold, or low 
temperature, that it is most influential as a febrific cause ; vicissitudes 
of temperature, sudden changes from warm to cold, or Irom cold to 
warm weather, are the sources whence febrile disease is so abun- 
dantly derived; and these changes are always injurious in proportion 
to the suddenness of the transition, and the greatness of the change. 
A very gradual change of atmospheric temperature rarely produces 
disease, except in such as are peculiarly predisposed to influences of 
this kind. The mode in which cold produces fever has already been 
explained. Its first effects on the system are torpor of the cutaneous 
exhalents, and a retreat of the blood from the surface to the internal 
organs. The recrementitious perspirable matter is thereby retained, 
and the blood rendered more irritating, or at least, surcharged with 
ofl'ensive substances. In consequence of these morbid conditions, the 
heart is excited into increased action, by which the blood is again 
propelled into the external capillary system, without, however, over- 
coming the torpor of the exhalents. If any portion of the capillary 
vessels be predisposed, by previous debility, to morbid excitement, 
high vascular irritation will be apt to occur in this part, and probably 
to the extent of actual inflammation. Should the mucous membrane 
of the respiratory passages be predisposed to irritation, catarrhal or 
pneumonic affections will be the consequence. If the alimentary 
canal be in a state of accidental or habitual irritation, dysentery or 
enteritis will probably occur. In short, whatever part of the system 
may be in a condition peculiarly predisposed to disease, inflammation 
or high vascular irritation will most likely be developed in it, by the 
increased momentum of the circulation, and the immediate local im- 
pressions of the recrementitious elements retained in the circulation.* 

When the degree of cold is excessive, or very prolonged in its 
action on the animal system, it gradually abstracts the animal tem- 
perature to a degree incompatible with vital action, and asphyxia^ 
gangre7ie, or death ensues. The tendency which very low tempe- 
rature has to produce these effects, is greatly controlled by the degree 
of constitutional energy, as well as the degree of corporeal exercise, 
of those who are exposed to its prolonged influence. A person of a 
vigorous and healthy habit of body, will readily bear a degree of 
cold without particular injury which would soon destroy an indivi- 
dual of a weak and infirm state of the system. In all instances where 
cold is applied in a degree capable of gradually reducing and finally 
arresting the vital actions, an indomitable inclination to sleep super- 
venes just before the fatal torpor comes on. When this oppressive 

somnolency ensues, all feelings of pain or suffering cease and if it 

be not resisted, death is inevitable. 

Heat. — High atmospheric temperature acts much more frequently 

* Dr. James Johnson, passim. 



MIASMATA. 53 

as a predisposing than an exciting cause of disease. « Solar heat," 
says Dr. James Johnson, "produces only the predisposition, while 
terrestrial exhalations and cold call into action the principal diseases 
of hot climates. The mode in which solar heat contributes to the 
production of disease, appears to be either by augmenting the general 
irritability of the system, or more generally, by exciting inordinate 
functional action of the skin and the liver, and thereby rendering 
them more susceptible of the paralyzing impressions of cold. Be- 
tween the skin and the liver there exists a close and powerful sym- 
pathy, in consequence of which, whatever excites the functions of 
the former, produces, perhaps, an equal increase of the functions of 
the latter organ."* Hence, high atmospheric heat very generally 
produces an increased secretion of bile, by its influence upon the liver 
through the medium of the skin, whose functions it is so peculiarly 
adapted to augment. It is manifest that an inordinate activity of 
these two functions from the influence oi heat, must render them ex- 
tremely obnoxious to torpor or inactivity from the sudden application 
of cold; and it is equally obvious, that a sudden torpor of these two 
important emunctories cannot occur without an immediate injurious 
consequence upon the whole system. Solar heat is, moreover, ex- 
tensively concerned as an indirect cause of febrile affections, by fa- 
vouring the production of marsh miasmata. By its expansive and 
exciting influence, it sometimes gives rise to sudden and dangerous 
local determinations, particularly to the head, causing apoplexy, and 
that state of cerebral oppression called a stroke of the sun. 

Sect. IV. — Of Miasmata. 

The term miasmata is here used as designating a highly important 
class of febrific agents of a gaseous form, which act on the animal 
system through the medium of the atmosphere. This class of agents 
consists of two orders, namely, — 1. Infection, comprehending those 
febrific effluvia which are generated by the decomposition of vegeta- 
ble and animal matter ; and — 2. Aeriform contagions, generated by 
the animal system in a state of disease. 

1. Infection, or that variety of febrific agents which is produced 
by decomposition out of the animal system, consists of two genera, 
namely; — 1. Those which result from the humid decomposition of 
vegetable and animal substances contained in the public filth of cities, 
in marshes, and in other soils and situations furnishing these mate- 
rials. This genus is usually designated by the term marsh miasm ; 
but from the common or public source of these morbific effluvia, it 
has been proposed, and by some adopted, with nmch propriety, I 
conceive, to distinguish them by the compound term koino-mias- 
mata. 2. Those febrific effluvia which are generated by the decom- 
position of the natural exhalations and excretions of the human 
body, accumulated and confined in crowded and ill-ventilated habi- 
tations. These deleterious effluvia, originating from the decomposi- 

* James Johnson, On the Influence of Tropical Climates, ^c. 



54 MIASMATA. 

lion of matter derived from the human body, have, with ^.^"^^ P[j^g 
priety, been designated by the term idio-miasmala, expressive ^^ 
personal or private character of their source.* Before ti-ea i ^ 
these febrific agents, in an etiological point of view, it will be Proper 
to describe, more circumstantially, the manner and circumstances in 
which they are generated, as well as their physical characters, so lar 
as these can be known. , 

1. KoiNo-MiASMATA, usually designated by the terms marsh-mias- 
mala, or ma/aria. This morbific agent was not unknown to tne 
ancient Greek physicians. They personified it under the emblem ot 
a many-headed monster, whose devastating influence was so severely 
exercised over the luxuriant fields of Argolis, that it was made one 
of the labours of the potent son of Alcmenus to rid the country of 
this dreaded source of pestilence, Hercules, accordingly, drained 
the extensive Lernean marshes, and thus dried up this abundant 
source of pestiferous emanations. 

■Heat and ?noisture are indispensable to the generation of koino- 
miasmata ; without these, no decomposition can take place, and with- 
out decomposition no deleterious agents can be generated from dead 
vegetable and animal substances, in latitudes where the atmospheric 
temperature seldom rises above 60°, the diseases which arise from this 
agent occur but very rarely, and perhaps, never in an epidemic man- 
ner. The Lithuanian marshes of Russia do not render the surround- 
ing districts insalubrious. It would seem, indeed, from a long series 
of observations, that kolno-miasmata are seldom evolved to a de- 
gree sufficiently copious or active to create extensive disease, so long 
as the temperature of the air does not rise above 80° of Fahrenheit, 
It is, however, not necessary that moisture should be present in great 
abundance for the production of miasmata. Indeed, grounds com- 

* These distinctive terms were originally proposed and adopted by the late 
Dr. Edward Miller, of New York, in the year 1804. He observed that there were 
two species of miasmata; the one consisting of febrific exhalations from marshes 
and other soils, and the other of effluvia generated by the decomposition of per- 
sonal and domestic filth. '' In order to distinguish these two varieties of miasmatic 
agents, and, at the same time duly to fix in the mind the impression of the origin 
and production of them, it is judged expedient to designate each by terms which 
will, invariably, express the process of nature in their formation. As the Greek 
language has been generally retorted to in the framing of scientific nomenclature, 
I shall employ the adjective KOIN02. common or public, to denote one species of 
miasma, and IA102, pcrsmml or pivatc, to denote the other. The application of 
these terms will be readily understood. That portion of the air charged with mi- 
asmata, exhaled by solar heat, from the surface of swampy ground, or from masses 
of filth overspreading the open area of cities, according to this distmction. is de- 
nominated Atmosphcra koino-miasmatica. And that other small portion of air con- 
taminated by miasmata, emitted from, and surrounding the body, clothes bedding, 
and furniture, of persons immersed in the filth of their own excretions and of 
those associated in the same family with them, accumulated, long retained and 

acted upon by animal heat, is denominated Atmosphera idio-miasmatica.'' Attempt 

to deduce a Nomenclature^ ^c. Med. Repository. New York, 1804. 



MIASMATA. 55 

pletely covered with water, send forth but very Httle of this dele- 
terious effliivinm, however favourable the temperature, and other 
circumstances may be. Hence, copious and continued rains by inun- 
dating marshy soils, render such localities comparatively salubrious, 
(Dalzille, Ferguson). Ferguson was led to infer, from his observa- 
tions on this point, that miasmata were extricated wholly indepen- 
dently of the humid decay or decomposition of vegetable and animal 
matter, and apparently without the agency of humidity. He asserts 
that this aeriform poison is never extricated, in any considerable quan- 
tity, until the moisture of the soil is so far dissipated as to leave the 
ground in the last stage of the drying process. This, however, is de- 
cidedly contradicted by almost universal experience. In proof of his 
opinion, among other observations, he says : " In the months of June 
and July our army marched through the singularly dry, rocky, and 
elevated country on the confines of Portugal, the weather having 
been previously so hot, for several weeks, as to dry up the mountain 
streams. In some of the hilly ravines, that had lately been waterr 
courses, several regiments took up their bivouac, /or the sake of 
being near the stagnant pools of water that were still .left among 
the rocks. Many men were seized with intermitting fever." From 
this, and similar facts, he thinks himself warranted to conclude, that 
the humid decay of vegetable and animal matter has no immediate 
agency in the production of miasmata, and that moisture, particularly, 
is not essential. But " half dried ravines and stagnant pools of water" 
are surely no evidence of a want of humidity, and present, one should 
think, precisely the conditions most favourable to the emission of mi- 
asmata from vegetable and animal decomposition. 

It may be observed, that in every instance adduced by Dr. Fergu- 
son, in proof that the extrication of miasmata does not depend on the 
humid decay of vegetable and animal matter, the soil from which 
the miasmata were emitted had been previously thoroughly saturated 
with water, during the rainy season, and moisture must, therefore, 
have existed in sutficient abundance, a short distance under the sur- 
face of the soil, however parched the latter may have been. Under 
such circumstances, miasmata might be abundantly sent forth, with- 
out any obvious humidity and vegetable decomposition, on the sur- 
face ; for the vegetable and animal remains, collected during the rainy 
season, must have been gradually decomposed during the drying 
process, and left, in part, at least, mingled with the portions of the 
soil on the surface. In this state, then, the slow evaporation of the 
humidity under the surface, in passing up into the air, would dissolve 
the putrid but dry particles of animal and vegetable remains, and 
convey them in the form of an effluvium into the circumambient 
atmosphere. 

That a considerable degree of humidity is especially favourable, 
and even essential, to the evolution of miasmata, is evident from the 
circumstance that marshes, stagnant pools, and the oozy shores of 
rivers, have, in all ages, and in all countries, been found the most 
insalubrious portions of the earth during the hot seasons. 

As to the variety of soil most favourable to the production of 



56 MIASMATA. 

miasmata, we possess no very definite or certain information. It as 
been asserted, that an argillaceous soil is most favourable for the ex- 
trication of this effluvium ; but its tendency in this way appears to 
depend solely on its greater compactness, in consequence ol which, 
it retains humidity much longer than other soils, and thus favours the 
formation of marshes, and of standing pools of water. 

It is not, however, from marshy or low and humid soils alone, that 
this morbific effluvium is disengaged ; for " there is scarcely a spot 
of this earth's surface to be found that is not covered or imbued with 
both vegetable and animal remains in a state of decomposition, 
and ready to aflTord pabulum for the sun's rays, with or without 
humidity to extricate malaria.* Wherever vegetable matter meets 
with sufficient heat and moisture to cause it to enter into humid de- 
composition, there miasmata will be evolved, and in our own climate 
there are very few, if any situations, that do not at times furnish all 
these conditions to a greater or less extent. 

A mixture oi fresh and salt water in marshes, appears to enhance 
the copiousness and virulence of miasmata to a very obvious degree. 
It is a singular fact, that the water of the sea is much more apt to 
enter into putrefactive decomposition than fresh water ; and this, no 
doubt, depends on the great quantity of organic matter which it con- 
tains. M. Monfalcon mentions some interesting examples illustrative 
of this fact.t The extensive pool of Valdec, in the south of France, 
is quite saline. Not more than a few rods from it is a large pool of 
fresh water called Engrenier. When the waters of these two pools 
rise, and run into each other, as they occasionally do, much sickness 
soon occurs throughout the adjoining parts. In the vicinity of Lukes, 
on the south of the Ligurian Appenines, there is a large marshy plain 
accessible to the high tides of the ocean. The neighbouring districts 
were almost uninhabitable from the pestilential effluvia which ema- 
nated from this marsh, until the waters of the sea were separated 
from the sweet water of the marsh by means of sluices and hydraulic 
works, when it became healthy, and the population increased rapidly. 
Of the nature of koino-miasmata, we possess, as yet, no certain 
knowledge. Examined chemically, the air of the most pestiferous 
marshes is found to differ in nothing from the purest and most salu- 
brious air. According to the experhnents of Professor Julia, of Lyons, 
it would appear that 

1. The deleterious influence of koino-miasmata depends on par- 

ticles of putrid animal or vegetable matter dissolved and sus- 
pended in aqueous vapour. 

2. The air of marshes does not differ from atmospheric air in any 

of the principles which chemical analysis can detect. 

3. None of the gases disengaged from bodies in a state of putre- 

faction, exhibit themselves in a sensible quantity. 

4. The disorders caused by koino-miasmata are not in any de- 

gree dependent on the predominance of azote, of carburetted 
hydrogen, of ammonia, of nitrous oxide, &c., in the air. 

* Dr. James Johnson, Med. Chir. Rev. 
t Histoire Medicale des Marais. Paris, 1828. 



MIASMATA. 57 

That koino-miasmata consist in particles of putrid vegetable and 
animal matter, dissolved in aqueous vapour, receives considerable 
support from the experiments of Gaspard and Majendie on the effects 
of putrid exhalations on animals, and which have already been cited 
in a former part of this volume. Majendie found, that on exposing 
different animals to the exhalations of putrid animal matter, affections 
were produced analogous to those which are known to occur in man 
from the influence of pestilential miasmata. It is not improbable, there- 
fore, that such putrid materials, suspended in vapour, constitute the 
deleterious principle of miasmata of this kind; and it may be reasonably 
presumed, that the different modifications of disease produced by this 
agent, in different localities, depend in a great degree on the different 
degrees of concentration, as well as on the particular character and 
proportion of the substances from whose decomposition the putrid 
miasmal particles are derived. It can hardly be doubted that the 
relative proportions of animal and vegetable matter which may enter 
into miasmal exhalations, will determine the violence of their inffu- 
ence, and modify its results on the system. Plausible as these senti- 
ments may be, it should not be forgotten that they are founded on no 
certain data, and that we may, after all, as yet be remote from the 
truth in relation to this subject. 

Whatever may be our views concerning the essential nature of 
koino-miasma, observation has made us acquainted with certain of 
its physical properties, as well as with its general effects on the human 
system, and which is perhaps all that it imports us, in a practical 
relation, especially to know. 

Koino-miasmata possess a greater specific gravity than atmospheric 
air (De Lisle). They cannot, consequently, ascend into the air with- 
out being attached to and carried up by lighter bodies: and these 
vehicles consist, without doubt, of aqueous vapours. Hence, persons 
sleeping in elevated chambers, are much less apt to contract miasmal 
diseases than such as are lodged on the ground floor (Hunter on the 
Diseases of Jamaica, Blane, Lempriere,"* De Lisle). And hence, too, 
the greater salubrity of hills, and very elevated parts, than the ad- 
joining low grounds. The ancient Romans appear to have been fully- 
aware of this fact, and they availed themselves of it by almost uni- 
formly selecting very elevated positions, or hills, for the sites of their 
towns. It is true, that some very remarkable exceptions have occurred 
to this fact. Bancroft mentions the great mortality which has repeat- 
edly been observed on the top of Montefortune, at St. Lucie : and on 
the Hospital and Richmond hills, at Grenada, while the surrounding 
low situations were comparatively salubrious. Dr. O'Hallaran, in 
his account of the yellow fever of the south and east coasts of Spain, 
mentions similar examples of the great prevalence of miasmal dis- 

* Drs. Blane and Lempriere, in their report to the Secretary of War concern- 
in"- the Walcheren fever, observe : " On no account should ground floors be used 
to sleep on : the more lofty the buildings the better, for the tenants of the upper 
stories not only enjoy the best health, but, when taken ill, have the disease in the 
mildest form." — Bancroft on Marsh Exhalations. 



58 MIASMATA. 

eases on very elevated situations, whilst the surrounding marshy 
grounds were but little infested with this deleterious effluvium_ ne 
refers particularly to Moiijui, a hill 700 feet high, overloolang mice- 
lona, the air of which, he says, is so deleterious, that it was lound 
necessary to relieve the stationary guard every eight or ten days ; and, 
he adds, that the injurious influence of the exhalations arising trom 
the swamps below manifested itself more conspicuously upon the 
, summit of the hill than in the subjacent parts. Dr. Blane, who men- 
tions similar facts, explains them by supposing that the vapours formed 
on the low and swampy grounds ascend, and, with the miasmata 
which they hold in solution, pass over the lower situations, and im- 
pinge and settle on the neighbouring hills. It is, indeed, by no means 
uncommon to see fogs, which rise out of the low grounds, ascend and 
hover over the tops of the neighbouring mountains, and it may well 
be presumed that these fogs will convey along with them a large por- 
tion of the miasmata which may be extricated from the same grounds 
whence the aqueous vapours rise. 

Kuino-miasmata are abundantly precipitated to the surface of the 
earth during the night, and more especially during the first hours 
after the setting, and shortly before the rising of the sun. Hence, in 
part, the greater liability of contracting miasmatic diseases from ex- 
posure between the setting and the rising of the sun than after the 
sun is considerably above the horizon (De Lisle, Bancroft, Sir James 
Fellows, Johnson). The most dangerous point in the twenty-four 
hours of the day is " that which accompanies the setting and that 
which immediately precedes the rising of the sun, and the least critical 
time is when the sun is at its highest point above the horizon" (De 
Lisle). In these facts we have strong evidence of the correctness of 
an observation already made — namely, that the miasma is united 
with and suspended in the air by aqueous vapour, which, falling in 
the form of dew, carries down along with it the deleterious miasma- 
tic particles. 

Koino-miasma may be arrested in its progress or passage from 
its source to other parts, by whatever is capable of impeding and in- 
tercepting the progress of aqueous vapour. Thus the interposition 
of a dense forest, of a iiigh wall or fence, of a chain of elevated hills, 
in short, of any mechanical obstacle of this kind, has been known 
to protect the inhabitants of villages, of camps, of convents and of 
single habitations, from the pestiferous influence of neighbouring 
marshes. De Lisle relates several very remarkable facts illustrative 
of this observation (Monfalcon, Bancroft). A convent situated on 
Mount Argental, near the village of St. Stephano, was, for a long time, 
remarkable for its salubrity, until the trees by which it was sur- 
rounded were cut down, when it became extremely sickly. From the 
same circumstance, miasmata are sometimes confined by obstacles of 
this kind, and so accumulated in particular localities, as to acquire a 
high degree of concentration and power. Marshes surrounded with 
dense forests, in warm climates, have often given unequivocal illus- 
tration of this fact. The same effect, in causing a stao-nation and 
accumulation of miasmata, has been observed in most situations 



MIASMATA. 59 

environed by high hills. In some of the valleys in the mountainous 
regions of South America, malaria are thus accumulated to a degree 
wliich gives them the utmost virulency, while the surrounding ele- 
vated parts are entirely free from miasmal diseases. This is remarka- 
bly the case of Jlcapxdco, which, as Dr. Macculloch* observes, may 
be regarded as a striking instance " of the imprisonment of malaria by 
hills." It is in this way, too, says this writer, that we '• may explain 
the peculiar virulence of jungles and pine swamps and even of woods 
everywhere." 

Considerable diversity of opinion has been expressed as to the dis- 
tance to which miasmata may be diffused from their source in a state 
of sufficient concentration, to produce fever. In a quiescent state of 
the atmosphere, the sphere of activity is probably much more limited 
than has been generally supposed, Bancroft thinks that they are 
rarely carried beyond a quarter of a mile, even by unobstructed cur- 
rents of air, in a state sufficiently active to produce fever ; and he 
adduces several observations which seem to confirm this opinion. 
Unquestionably, however, currents of air passing over marshes often 
convey the miasmata which arise from them to a very considerable 
distance — sometimes several miles, in a state of concentration fully 
adequate to the production of their usual deleterious effects on the 
human system. " In Italy," says Dr. Macculloch, " the poisonous ex- 
halations of the lake Agnano reach as far as the convent of Camal- 
doli, situated on a high hill, at the distance of three miles, proving 
that thus far, at least, malaria can be conveyed by the winds." The 
account of the thirty Roman noblemen, mentioned by Lancisci, is an 
interesting and striking illustration of this fact. They were sailing 
near the mouth of the Tiber, on a party of pleasure. Suddenly the 
wind shifted, and blew over the putrid marshes. Twenty-nine out 
of the thirty were soon seized with intermitting fever. The effects, 
often truly frightful, of the harmuttan, after becoming loaded wilh 
the pestilential effluvia of the swamps of Benin, afford also a strong 
illustration of this fact. From this circumstance it not unfrequently 
happens that those who reside on the leeward margin of marshes, or 
sluggish streams, are extremely harassed by miasmal diseases — while 
those who sojourn on the windward side remain almost entirely ex- 
empt from these affections. Dr. Macculloch relates an instance from 
his own observation, which strikingly illustrates this fact. " An army 
was encamped in a very pestiferous plain, yet the health of the men 
did not suffer, because, being near the shore, the sea-breezes predomi- 
nating at that season, swept back the malaria into the interior coun- 
try. From some cause the encampment was transferred to another 
point, without recollecting that the change of the regular winds was 
approaching. They did commence — sweeping in a new direction 
across the plain; and, within a ie'vi' days, many thousand men were 
disabled or destroyed." 

During the autumns of 1820, '21, '23, and '24, there was scarcely 
a family between the eastern shore of the Schuylkill and the city 

* An Essay on the Production and Propagation of Malaria, &c. 



60 MIASMATA. 

of Philadelphia, that did not suffer from intermitting and remitting 
fevers; whilst among the inhabitants of the western shore, and of the 
high grounds a short distance back, there was, comparatively, but 
little sickness. The cause of this difference manifestly consisted in 
the course of the wind, which, during the periods here mentioned, 
as indeed is generally the case, blew almost continually from the 
west, northwest, or southwest; and thus swept the miasma, which 
Avas generated along the oozy borders of the Schuylkill, in an eastern 
direction. 

Violent storms, and copious showers of rain, tend powerfully to 
free the atmosphere from koino-miasmata. The former violently 
disperses them, and the latter sweeps or washes them down to the 
surface of the earth. Nothing is more common than to find mias- 
matic epidemics to remit immediately after copious floods of rain or 
violent storms (Rush, Bancroft, Monfalcon). 

A humid air is a much better vehicle for the transportation of mias 
matic exhalations than a dry one. The particles of the miasmatic 
poison attach themselves to the humidity of the air, and are thereby 
carried along by currents of wind. It is to be remarked, however, 
that, although atmospheric humidity appears to favour the dissemi- 
nation and action of miasmata, yet observation would seem to show 
that when these effluvia pass over a surface of water, they become 
absorbed, or in some way lost. This circumstance may, in part, 
account for the short distance assigned by Bancroft to the dissemina- 
tion of miasmata from their source ; for in all the examples which he 
adduces in support of this opinion, the miasmata were conveyed over 
bodies of water. 

II. Idio-miasmata — This variety of miasmata is generated by the 
decomposition of the matter of perspiration, and the other excretions 
of the animal body ; and hence it most frequently occurs in the con- 
fined and crowded hovels of the j^oor, in crowded jails, ships, hospitals, 
and wherever many individuals are confined in apartments not duly 
ventilated. From an inability to procure separate dwellings, the 
poor are generally obliged to take up with small apartments, into 
which two or three families are often crowded ; and in order to save 
fuel, and indeed frequently from the total want of fuel, every access 
of the external cold air is carefully cut off. Add to this the fihh and 
want of proper changes of clothing, almost inseparable from extreme 
poverty, and you have a combination of circumstances peculiarly 
calculated to generate a miasma, by the putrefactive decompositioti 
of the animal exhalations with which the air and every article of 
clothing in such apartments must be saturated. It is chiefly during 
the cold season of winter that this variety of miasmata is generated. 
When the weather is warm, the air of crowded and filthy apartments 
is constantly renewed by the doors and windows being kept open, and 
the accumulation and stagnation of the animal exhalations thereby 
prevented. Dr. Smith observes, that this miasm is especially apt to 
be generated in the apartments of the sick, particularly "of those 
who are labouring under the typhus state of fever."* It may be 

* Elements of the Etiology and Philosophy of Epidemics, p. 52. 



MIASMATA. 61 

observed, however, that the exhalations which emanate from the body- 
in a state of disease, and which possess the power of producing the 
same disease as that, under whose influence they are evolved, cannot, 
with strict propriety, be ranked with the present class of miasmal 
poisons. They belong to the contagions. I would restrict the term 
idio-miasjua to those morbific effluvia which are generated by the 
decomposition of the animal secretions, whether formed in a state 
of health or disease, and to the ordinary exhalations from the body, 
when accumulated in such a manner as to deteriorate the atmosphere 
of confined rooms, if these be really capable in themselves, and with- 
out decomposition, of exciting fevers. 

Idio-miasmata are always quite limited in the sphere of their in- 
fluence. Beyond the room or habitation in which they are generated 
their operation cannot extend ; miless, indeed, they are absorbed or 
adhere to articles of clothing, and are conveyed abroad in a state of 
sufficient activity to act on the hmnan system. Whenever fever is 
found to spread from a source of idio-miasmata, it is in consequence, 
doubtless, of the generation of a new contagious miasm by the disease, 
which is produced in the first instance by the idio-miasmatic poison. 
I am well aware that this opinion involves what has been declared 
a manifest inconsistency — namely, the origination of a contagions 
disease by a common or general exciting cause. All such objections, 
founded merely on speculative inferences, may be met by facts, which 
must stand good, however irreconcilable they may appear to be with 
the dogmas of philosophy, or with admitted principles. It is a. fact, 
for instance, that typhus may be originated by the miasm resulting 
from the decomposition of the secretions or exhalations of even healthy 
individuals, crowded and confined a long time in narrow and unven- 
tilated apartments. And that, although not necessarily a contagious 
malady, typhus may, under peculiar circumstances, generate a specific 
virus which is capable of exciting the same disease in others, is a 
fact supported by a mass of testimony which cannot be reasonably 
rejected. " There are few physicians," says one of the most eminent 
medical writers of the present day,* "who believe that epidemic or 
endemic fevers arise from specific contagion, though facts daily teach 
us that typhus, yellow fever, dysentery, &c., occasionally, and under 
particular circumstances, give out a something (call it what you 
please), which produces a similar disease in the healthy stander-by, 
who happens to come within its range. If we may venture to prog- 
nosticate, we would anticipate that this tvill be,asit assuredly now is, 
the more general opinion among practitioriers.'' 

From the circumstance of this variety of miasmatic poison " be- 
coming innoxious when diff'used in the atmosphere, even a few feet 
beyond the apartments in which it is generated," none of the forms 
of disease, which it is capable of producing, are apt to occur epidemi- 
cally. Typhus, nevertheless, has been known to occur in a manner 
well entitled to the name of epidemic. The late widely-spread epi- 
demic of Ireland was surely strongly characterized in its progress and 

* Dr. James Johnson, Med. Chir. Rev., vol. vii. (1825,) p. 65. 



62 , MIASMATA. 

extent of diffusion by every feature which can give to diseases the 
character of an epidemic. 'Though engendered and nursea in itie 
lap of wretchedness and poverty, it did not, in its desolating sway, 
fall exclusively upon those who were suffering under the distressing 
privations of penury. Its fatal visitations were abundantly made to 
the ample and airy habitations of plenty and comfort, and almost- 

Ecquo pulsat pede pauperum tabernas 

Regumque turres. 
The question here occurs: "If idio-miasma becomes innoxious 
by being diffused in the atmosphere even a few feet beyond the apart- 
ments in which it is engendered," how can typhus, which is mani- 
festly originated by this effluvium, become epidemic, or be produced 
in large and well-ventilated dwellings remote from the usual sources 
of this miasm? Is it by the idio-miasma attaching itself to the 
clothes of individuals, or to other substances by which it may be con- 
veyed from one to another place ? If this be admitted, then idio- 
miasma must possess the character of a contagion. Is it not more 
probable, that in the majority of instances of this kind, the disease is 
propagated by a specific virus, generated by a morbid secretion, and 
conveyed as other contagions of an aeriform character are conveyed ? 
It does not seem probable that idio-miasmata can be disseminated by 
fomites. If it can be so disseminated, it must possess all the charac- 
teristics of a veritable contagion. 

Of the relations of Miasmata to the Jlnim.al System, 4'C. 

Having given an account of the physical character and conditions 
under which the two infectious effluvia, Jeoino and idio-miasmata, 
are evolved, I proceed to the consideration of their relations, as mor- 
bific agents, with the human system, as well as with each other. Upon 
this subject I stand largely indebted to the ingenious and truly philo- 
sophical work of Professor Smith, of New York ; for, although 1 have 
long since entertained similar views in relation to the combined agency 
of these miasmal poisons in the production of fevers, yet the enlarged, 
systematic, and precise views taken of this subject by Dr. Smith, have 
afforded me some new and interesting insights into this part of the 
etiology of fevers. 

The class of fevers arising from koino-miasmata are very distinct 
in their general character, and we may presume, in their essential 
natures, from those which are the result of idio-miasmata. The 
former give rise to intermittent, remittent and bilious fevers ; and the 
latter miasm is the source of typhus, and the low nervous fevers of 
former writers. 

The deleterious power of koino-miasmata is manifested not only 
by the violent and fatal fevers which they are known to produce so 
abundantly, but also by the more slow inroads they make on the 
physical and moral condition of those unfortunate beino-s who are 
habitually exposed to their influence. The indigenous inhabitants ot 
marshy districts, in warm climates, present an aspect of suflerin<^ and 



MIASMATA. 63 

wretchedness from this cause which is well calculated to draw forth 
the commiseration of those who are more fortunately located. Con- 
tinually exposed to the deleterious influence of these baneful exhala- 
tions, man, in such situations, exhibits a state of feebleness and early 
decrepitude, strongly indicative of a broken-down constitution, and 
deep, irremediable chronic disease. So deep and pervading, indeed, 
are the effects of malaria on the human system, that it never fails to 
debase, in a remarkable manner, both the physical and moral consti- 
tution of a people, who, through successive generations, reside in situa- 
tions abundant in perennial sources of miasmata. Not only does the 
stature and symmetry of the body suffer conspicuous deterioration, 
but the mind becomes torpid, feeble, pusillanimous, and the moral 
sentiments debased. 

But while such chronic and constitutional effects are wrought by 
the habitual endurance of koino-mias-mn, the system loses its sus- 
ceptibility of Ijeing excited into those violent commotions of febrile 
action which this agent is so apt to produce in individuals less accus- 
tomed to its impressions. The natives of marshy districts are com- 
paratively much more rarely affected with the higher grades of mi- 
asmal fevers than those who are only occasionally brought within the 
sphere of its influence. In the former, the agency of this poison pro- 
ceeds as it were by a slow and concealed combustion, whilst in those 
who are not accustomed to its influence, its effects burst out in a 
raging and rapidly consuming flame. 

There can be but little doubt that koino-miasma varies in its 
powers, and often very considerably, according to various circum- 
stances in point of locality, and the relative proportions of the animal 
and vegetable matter which supply the materials for its composition. 
Dr. James Johnson, whose authority I am always disposed to respect, 
has expressed his belief in the occurrence of such diversities in the 
peculiar morbific powers of this agent. "The fever of Batavia," he 
observes, " differs from the fever of Walcheren— the fever of Antigua, 
from the fevers of the Ganges — and all these differ materially from 
the plague of the Levant." That certain countries and localities have 
an especial tendency " to generate one mode or variety of fever, 
while, in other situations, some other variety as exclusively prevails," 
is an observation founded on abundant testimony of unquestionable 
authority. In Germany, intermittcnts almost universally assume the 
tertian type ; in Italy, the quotidian type greatly predominates ; and 
in Hungary, paludal fevers are peculiarly apt to be attended with 
petechias. " The fevers of the Pontine marshes are noted for the short- 
ness of their intermissions; whilst Holland is not less remarkable for 
the variety of the types than the slow progress of the fevers. In Spain, 
as in Africa, the West Indies, and the southern parts of the United 
States, the black vomit and the yellowness of the skin are similarly 
characteristic symptoms."* Even in localities situated within a short 
distance from each other,^the most remarkable difference occurs in 
the character of the fevers which they engender. Thus, " the fevers 

* An Essay on Malaria, &c., by John Macculloch, M. D. 



64 MIASMATA. 

of Walcheren," says Dr. Macculloch, "differ materially from those 
of Bresken on the opposite shore of the Scheldt ; and ni Frnnce those 
of Rochefort differ as completely from those of the Lyonnais. 

It cannot be presumed that the relative proportions of animal ana 
vegetable matter should be the same in different localities, arid equally 
improbable is it that the same kinds of these materials should be pre- 
sent in the different situations where miasmata are generated. 1 here 
mast be great diversity in both these respects, and a corresponding 
diversity in the essential morbific qualities of the miasmata evolved 
from them. I have already mentioned the experiments of Majendie 
in relation to the effects of putrid animal substances on the animal 
system. From these, it appears, that " different kinds of flesh, when 
in a putrid state, produce different effects on the animal ecomomy,"* 
and it is, therefore, reasonable to conclude that miasmata will differ 
in their powers according to the greater or less proportion and kinds 
of the animal and vegetable matters concerned in their production. 

The influence oi koino-miasmata on the human system, like that 
of other general causes of disease, is much under the control of the 
physiological state of the animal economy, of idiosyncrasy, of tem- 
perament, predisposition, and of accidental external causes. Thus of 
a number of individuals exposed for a certain time to the same mirnim, 
some may become affected with intermittent fever, others with mild 
remittent fever, some with malignant bilious fever, some with bilious 
colic, some with dysentery, and others, perhaps, will escape the disease 
entirely. 

The influence of high atmospheric temperature in predisposing the 
system to the deleterious impressions of miasmata is, probably, very 
considerable. Long-continued exposure to solar heat appears to have 
an especial tendency to affect the biliary organs, and lo render the 
system generally irritable. These conditions, it may be presumed, 
are peculiarly favourable to the morbific influence of malaria ; and 
it is not improbable that they sometimes contribute, in a considerable 
degree, to render the miasmatic fevers of intertropical or hot climates, 
so peculiarly violent and dangerous. Dr. Macculloch dwells much 
on " errors of diet" as a predisposing cause of the miasmal fevers. It 
would appear, that the free use of animal food, in tropical climates, 
is peculiarly calculated to favour the morbific influence of miasmata; 
and this is said to be especially the case when the animal food is taken 
" in the middle of the day, or frequently in one day." On examining 
Niebuhr's narrative, says Dr. Macculloch, " it is most apparent that 
the deaths of his companions were the consequences of gross feeding." 
<•' On this question," says the same writer, "there can perhaps be no 
better evidence than the opinions and practices of the intertropical 
nations themselves, among the mass of whom this subject seems well 
understood ; while in many countries it is a caution actually often 
given to Europeans by the natives, though most generally neo-lected 
by them. It is, probably, from long experience, in some measure of 
its advantages, as well as from more obvious causes, that a vegetable 

* Journal de Physiologie, Janvier, 1823. 



MIASMATA. 65 

diet is so general throughout the aborigines of the torrid climates ; 
while it is doubtless from principle, also, that among the people of 
Africa, to the northward, at least, the sole or the principal meal is 
supper." 

The class of diseases produced by koino-miasmata, if we take into 
view their various modifications, is by no means limited in its range. 
The most simple form of disease arising from this cause is the inter- 
mittent fever. In proportion as this febrific effluvium increases in 
potency, so does it produce fevers of a higher and more violent grade. 
The range of activity of this miasma extends from the simple tertian 
of the temperate latitudes to the malignant and fatal plague of the 
East, or the scarcely less fatal bilious fever of Batavia. 

Besides general fevers — assuming an endless diversity of character 
in different seasons and climates, koino-miasmata produce, also, vari- 
ous other affections, both local and general. Dysentery, cholera, and 
diarrhoea, are enumerated among the maladies produced by malaria. 
It may be doubted, however, whether miasma, by itself, without 
the co-operation of other causes, has any particular tendency to excite 
those afiections. I apprehend, that in many instances occurring in 
malarious districts, as elsewhere, atmospheric vicissitudes, or cold, 
exerts no small degree of influence in determining the disease upon 
the alimentary canal. During the autumn of 1814, one-fourth, per- 
haps, of the men of four regiments encamped near Baltimore, were 
affected with intermitting and remitting fever in the month of Sep- 
tember. The weather was remarkably warm, equable and dry. The 
months of October and November, however, were rainy, extremely 
variable in temperature, and the majority of the men, who were pre- 
viously lodged in covered rope-walks and houses, were now encamped 
in tents. A week after the rainy and cold weather set in, dysentery 
and diarrhoea began to appear abundantly, and in the course of three 
weeks more, there were but very few cases of intermitting or remitting 
fever, but more than eight hundred cases of dysentery. Neverthe- 
less, the capability of miasmata of producing these forms of intestinal 
disease by its own unaided powers, is not to be questioned, although 
it is, 1 think, equally evident, that the co-operation of sudden changes 
of atmospheric temperature, or cold, is especially calculated to enhance 
the tendency of the miasmata to occasion these diseases. From these 
remarks, cholera ought to be excepted, for the cholera of India, at 
least, is most undoubtedly the product of a miasmatic agent. 

Dr. Macculloch mentions tic douloureux as a common consequence 
of the influence of miasmata — more especially in Italy ; and the 
occurrence of periodical hemicrania, from this cause, is by no means 
unfrequent even in our own climates. In truth, there is scarcely a 
malady that may not be produced or simulated by the operation of 
malaria on the human system. 

The period which intervenes between the reception of koino-mias- 
ma and the first manifestation of its influence on the human body, 
is extremely various. Of many persons exposed to it at the same 
time, some may be immediately affected, others in a few days, some 

VOL. I. — 5 



66 



MIASMATA. 



not until several weeks have passed, whilst others may remain free 
from its effects a still longer time. 

As the powers of koinomiasmata most probably vary considera- 
bly in different countries and localities, it may be inferred, as has al- 
ready been observed, that the fevers which they produce are impressed 
with a corresponding diversity in their character; and observation 
would seem to confirm this inference. Dr. Smith thinks, that what- 
ever external or general diversities may occur in fevers produced by 
this miasma, " their pathology or essential nature is everywhere the 
same." This is highly probable ; for the diversities in question would 
seem to depend more on the mere grade of violence, local affections, 
and general course of these fevers, than on any radical difference in 
their essential pathological conditions. Upon this point, however, it 
becomes us to speak with diffidence, as this question cannot be solved 
by mere closet inferences and reasonings, but by close observation and 
careful experience, in relation to these fevers as they occur in various 
countries, climates, and localities. 

V How far a mixture, or the combined agency of koino and idio- 
miasmata, may operate in producing novel or anomalous varieties 
of fever, it is impossible to say ; but that such a combination does 
sometimes occur, and give rise to fevers of a peculiar or mixed cha- 
racter, will scarcely be doubted by any one who has given due atten- 
tion to this interesting subject. Professor Smith, to whose work I 
have already so frequently referred, has given this subject a compre- 
hensive and minute consideration, and to whom, indeed, the credit is 
due for introducing this interesting point of etiology to the notice of 
the profession. « Let us suppose," says Dr. Smith, " the circumstances 
in which typhus originates, to occur in summer, such as the crowding 
of individuals into small apartments, badly ventilated, and rendered 
offensive by personal and domestic filth. These causes would obvi- 
ously produce typhus in its ordinary form. But suppose there exist 
at the same time, those exhalations which occasion plague and yellow 
fever, or intermittent and remittent fevers. Under such^circumstances, 
we should not expect to see any one of those diseases fully and dis- 
tinctly formed, but a disease of a novel or modified character." There 
exists no doubt in my mind, of the correctness of Dr. Smith's obser- 
vation, that the late Bancker Street fever in New York, as well as the 
peculiar fever which prevailed among the blacks in this city, a few 
years ago, was engendered by the united influence of these two mias- 
mal poisons. I once had a striking illustration of the anomalous and 
fatal character which the united action of koino and idio-miasmata 
IS apt to impart to fever. During the fall of 1814, while attending 
m the capacity of regimental surgeon, in the encampment at Balti- 
more, ten men affected with mild remitting fever were lodged in a 
room of confined dimensions, and as the weather was cold the room 
was kept pretty warm by fire, and the doors and windows as little 
opened as was admissible. The adjoining room was exceedindv 
crowded with mvalids, and but little attention paid to cleanliness and 
ventilation. In a short time several cases of fatal typhus occurred ir 
this room. Soon after this, the patients who were afiected with inter 



m 



MIASMATA. 67 

mitting fever in the next room, manifested new and more alarming 
symptoms ; blood began to ooze from their gums ; extreme tender- 
ness of the epigastrium occurred ; the intellect was but little disturbed ; 
the eyes were dull, watery and staring ; the temperature of the skin 
and the pulse nearly natural ; the animal powers so little prostrated, 
that one of the men died a few minutes after he had been sitting up 
with his back leaned against the wall of the room. They were all 
immediately removed to the Baltimore Hospital, and all except one 
died in a few days. There can be no doubt that this peculiar modi- 
fication of febrile disease was the result of the impressions of idio- 
miasmata (engendered in the house), made on systems already under 
the morbific influence of koi no-miasmata* 

* A considerable effort has of late been made to destroy the doctrine of miasma. 
Dr. Willis, in his treatise on the Pathology of Fever, totally denies the existence of 
miasma, and inscribes all its imaginary influences to moist warm air. He advances 
many arguments in favour of this idea, and quotes the observation of Fourcault, 
that a healthy animal will soon die if its body be covered with an impervious 
glaze. " Becquerel and Breschet, repeating the experiment of Fourcault, discovered 
that the extinction of life under such circumstances was accompanied by a signal 
fall of temperature; the animal whose body was endued with an impervious 
glaze, began to lose heat on the instant, and the loss never ceased till life had 
fled." The function of the skin is intimately connected with vital manifestations 
— and Dr. Willis conceives that this explains why such serious consequences 
should follow its derangements. " In a hot, dry atmosphere animals perish from 
the effects of excitement; in a warm, moist air of a temperature no higher than 
that of their own bodies, they die as they do when covered with an impervious 
glaze — the conditions requisite to the access of oxidized plasma, and the removal 
of deoxidized plasma are wanting, and life ceases as a matter of course."' 

The reviewers, who show the greatest deference to the views of Dr. Willis, at- 
tribute much importance to the fact that the dew-point in warm and moi-st situation.? 
is very little below the temperature of the atmosphere: and also to the new ob- 
servation of Fourcault, that albuminous urine is produced by covering an animal 
with glaze. Notwithstanding the ingenuity of these ideas, and the importance of 
these facts, it will be found very difficult to overcome the weight of evidence 
brought forward in the preceding chapter to prove the existence of miasma from 
the influence of winds, situation, atmospheric vicissitudes, &c. 

This theory of Dr. Willis is, moreover, very deficient in the way of accounting 
for the varieties of such fevers as are usually attributed to the different forms of 
marsh effluvia. How can a single cause like " warm and moist air," produce a 
quotidian in one place, a tertian in another, a bilious remittent in others — with all 
the various epidemic and endemic complications of them that are so constantly 
remarked by authors and practitioners ? How can a mere exposure to such a 
condition of the air produce a predisposition to fever which is frequently not 
developed until the lapse of many weeks'? There is no validity in the argument 
that miasm does not exist, because we cannot analyze it by chemical reagents. 
We do not doubt the existence of the contagious cause of small-pox, although no 
chemistry can appreciate it. — (Mc.) 



GS CONTAGION. 

Sect. Y.— Of Contagion. 

By a contagion is understood a deleterious agent secreted by the 
animal body m a state of disease, wliich, wher) brought to act on a 
heahliy individual, will produce a disease specifically similar to the 
one from which it derives its origin. Contagions occur under two 
distinct forms, and may therefore be divided into two varieties : viz. 
1. Those which consist of ?, pulpable mutter ox virxis ; and, 2. Those 
which consist of an imperceptible effiuvixnn. The chrome conta^ 
gious maladies are propagated exclusively by a palpable virus, and 
consequently always by actual contact. Those acute contagious dis- 
eases which are not attended by a specific local affection, or an exan- 
theme, are, on the other hand, exclusively propagated by a morbific 
contagious ejflvvium, and by consequence, solely through the medium 
of tlie atmosphere. Those actite diseases, which are essentially con- 
nected with a specific local affection, or «w exantheme, are commu- 
nicated both by a palpable virus, and by an imperceptible efiluvium, 
and consequently both by actual contact and through the medium of 
the atmosphere. We perceive, therefore, that of the extremes of a 
purely local, and a purely general malady, there is, on the one hand, 
communication of the disease solely by a palpable matter, and, on 
the other, by effluvia only ; and that where the local and the general 
affections meet in the same disease, as essential concomitants, (in the 
exanthemata,) there the two modes of propagation also obtain.* 

It must be observed, however, that though in a practical point of 
view we may properly adopt these distinctions between contagions 
communicated by contact and through the medium of the atmo- 
sphere, yet, in reality, an actual contact must, necessarily, always 
occur between the contagion and the individual, before it can possibly 
produce disease, whether the contagion be a palpable matter, or an 
imperceptible miasm. The only material difference consists in the 
mode in which this contact is effected. 

One of the most remarkable peculiarities of contagious diseases, is 
their inherent and undeviating tendency to preserve their essential 
individuality, under whatever circumstances of age, sex, constitution, 
temperament, modes of living, climate, and place, they may occur. 
Thus, the small-pox of the present day differs in no essential circum- 
stance from the same disease as it was observed and described by 
Rhazes more than eight centuries ago ; and the itch has changed in 
nothing since the time of Galen. Any certain contagion can, so far 
as we know, produce only one disease ; and if the system has become 
insusceptible of such disease, its peculiar cause is no longer a morbific 
agent in relation to that system. 

The laws of the acute contagious diseases differ entirely from those 

* This arrangement is adopted from Dr. Hosack's very lucid classification of 
contagions and their peculiar diseases. There is no writer of the present day 
whose views upon the character and arrangement of this class of maladies de- 
serve higher respect and attention than those which have been promul<Tated by 
Dr. Hosack. 



CONTAGION. 69 

which govern the rise, progress and declension of the chronic conta- 
gious aflections. The former observe the utmost regularity in all these 
respects. The rise, advancement and decline, in" short, the whole 
series of essential phenomena, are governed by laws as steadfast as 
those which regulate the motions of the planets. The latter class 
of diseases, on the contrary, are extremely irregular in their course, 
having no definite period of duration, nor established order and dura- 
tion of the successive phenomena of their course. 

The power which the acute contagious diseases have of destroying 
the susceptibility of the human system, to the subsequent influence 
of their specific causes, constitutes one of the most remarkable and 
mysterious characteristics of this class of maladies. In this respect, 
they difier as far from the chronic affections of this kind, as they 
do from the febrile diseases produced by general or non-contagious 
causes. In consequence of this law of acute contagious diseases, no 
malady of this kind can ever relapse during the period of conva- 
lescence. 

Considerable diversity of sentiment has been expressed in relation 
to the distance to which contagious miasmata may be dispersed from 
their source, in a state of sufficient activity to generate disease. That 
their sphere of activity is very limited, however, has been abundantly 
demonstrated, both by direct experiment and observation. The ex- 
periments of Dr. 0. Ryan, professor of physic in the college of L\ ons, 
prove that the contagious miasm of small-pox does not extend more 
than a few feet beyond its source.* The most malignant contagions 
are rendered inert and harmless by being diffused in the atmosphere, 
and even by diffusion in the air of a weli-ventilated apartment. Ven- 
tilation diminishes the activity of contagious effluvia simply by diffus- 
ing the miasm in a large portion of atmospheric air, in consequence 
of which those who become exposed to it, receive it in weak and 
inefficient doses. 

Contagions are perpetuated and conveyed to great distances from 
their source, by being absorbed by, and attached to, various sub- 
stances, such as clothing, furniture, bedding, &c., with which they are 
often transported even across the ocean. Animal substances, such 
as wool, hair, and articles manufactured from them are said to retain 
contagious matter with the greatest tenacity. The more the sub- 
stances which have become saturated with contagion are kept from 
the access of the open air, the more virulent and active will be its 
powers when it is brought to act upon the human system. Thus 
articles of clothing, after having been impregnated with contagious 
virus, will retain the power of infecting much longer, and in much 
greater intensity, if they are kept confined in close rooms, or locked up 
inchests or closets, than when they are freely exposed to the open air. 
It is by articles of this kind, locked up in trunks, that the small-pox, 
and other contagious maladies, have been conveyed to distant parts 
of the world in ships, although no person on board may have been 
sick with the disease during the voyage. The articles which are thus 

* Rees's C)'clopacdia ; ait. Contagion. 



70 CONTAGION. 

imbued with contagious virus, are called fomiles. It was the <^P"|J 
of Cullen, that contagions are more powerful when they are mus 
lodged in fomites, than when they arise immediately from the tiuman 
body, or when in a separate state. The same opmion is expressea 
by Dr. Lind. . , 

The influence which peculiar atmospheric constitutions have on 
the activity of contagions, and on their tendency to dissemination, is a 
subject as interesting as it is inscrutable. The most careless obserya- 
tion is sufficient to convince any one, that there exists in the varying 
constitutional, or perhaps accidental conditions of the atmosphere, a 
powerful modifying principle in relation to the powers of contagious 
agents. At times, it would.seem impossible for a contagious disease 
to extend the sphere of its ravages ; for, although sporadic cases may 
occur here and there, yet no neglect in relation to proper seclusion 
will enable the disease to assume an epidemic or endemic character. 
During other periods, on the contrary, the accidental importation of 
fomites, or the occurrence of a case of contagious disease, acts like 
a spark of fire thrown among combustible materials, and speedily 
spreads disease extensively among the people. The same powerful 
atmospheric influence shows itself in the diversity of character, in 
relation to the grade of violence, malignity, and general diathesis, 
which the same malady is observed to assume at different periods of 
its prevalence. That these things depend on some modifying agency 
of the atmosphere, there can exist but little doubt. What this condition 
of the atmosphere consists in, it seems impossible to ascertain; it is 
probable, however, that it has no immediate connection with either 
the temperature or the hygrometrical state of the air; for with the ex- 
ception of typhus, which is manifestly favoured by cold weather, the 
contagious diseases of every kind prevail equally during the heat of 
the summer and the cold of the winter. The mode in which conta- 
gions are either favoured or retarded in their progress, by atmospheric 
constitutions, consists, probably, not in any influence which they may 
exert immediately on the powers of the contagion, but rather, perhaps, 
in their tendency to modify the human constitution, so as at one time 
to render it peculiarly susceptible of the influence of the contagion, 
and at another to diminish, or for a time to annul, the natural predis- 
position to its operation. 

Of the primary source of contagion we know but very little. It 
is probable that each contagious disease was at first developed, 
independent of contagion, by the accidental concurrence of various 
circumstances, which, in the infinite series of such contingencies, 
may not again occur for many centuries. That a disease may be 
originated by the concurrence of general causes, without the agency 
of a contagion, and which may afterwards communicate itself to 
others, by a specific virus of its own elaboration, we have a familiar 
example both in typhus fever and in itch. There is reason to believe, 
indeed, that various corUagions have been thus produced, which have 
long since passed away from the face of the earth ;* and it is not an 

* The s^jJor AnLlkanus. so accurately desciibetl by Cams, appears to have been 



CONTAGION. 71 



idle conjecture to say, that new contagions may hereafter arise 
which, after having exhausted their power on mankind, may again 
disappear for ever, or until a similar concurrence of causes, which at 
first evolved the contagion, again occurs. 

It is an interesting fact, that contagious diseases sometimes origi- 
nate in the lower orders of animals, and are afterwards communicated 
to the human species. Hydrophobia and the vaccine disease are 
familiar examples of this kind. Professor Remur has published 
some observations which go to show that other diseases, such as the 
virulent coryza of horses, the plica of long-haired animals, and the 
gangrenous inflammation of the spleen, which occurs in cows, may 
be communicated by immediate contact to man. 

The following rules have been recommended for preventing the 
spread of contagious maladies to those who are obliged to approach 
patients labouring under diseases of this kind (Haygarth). 

1. "The chamber in which the patient lies must be kept clean 

and freely venlilaled. No bed curtains must be allowed to 
be drawn around the patient." 

2. " Dirty clothes, utensils, &c., should be often changed, and im- 

mediately immersed in cold water; and washed clean when 
taken out." 

3. " The discharges from the patient must be instantly removed ; 

and the floor around the patient should be rubbed clean once 
a day with a wet cloth." 

4. " Avoid the current of the patient's breath, as well as the efflu- 

via which ascend from his body, and from the evacuations " 

5. " Visitors ought not to go into the patient's chamber with au 

empty stomach ; and, in doubtful circumstances, on coming 
out they should blow from the nose and spit from the mouth 
any contagions poison which may adhere to these passages." 
Although it is quite certain that contagions will adhere to and 
imbue various substances, especially clothing, so as afterwards to 
reproduce the same disease, at a distance from their source, and 
often a long time after they had been generated ; yet it seems to be 
well ascertained, that such substances (clothing) can rarely be so 
greatly imbiTed with contagion by a slight and transient exposure 
to the poison, as to be capable, afterwards, of producing disease in 
the healthy. The clothes of transient visitors, for instance, will 
scarcely ever imbibe sufficient contagion to communicate the disease 
to others. Dr. Clark affirms, " that in eighteen years of medical 
practice, he never communicated the contagion of small-pox nor of 
scarlet fever to any one, although he had frequently, on the same 
day, visited many patients sick with these diseases, and in their most 
malignant forms." 

a highly contagious disease. It visited England five times in the period of sevea 
years, and sv^ept off a vast number of victims by its fatal violence. In many in- 
stances, those who were affected with it died within an hour, and few who sank 
under its malignity suffered longer than four or five hours. It has not been 
known to occur for several centuries past, its contagion having long since become 
wholly extinct. *- 



72 



CONTAGION. 



Mere ventilation is inadequate to destroy the contagion deposited 
in fomites. To efTect this important object, a great variety of means, 
such as exposing them to various vapours and fumes, have been de- 
vised. Without enumerating the difierent disinfecting agents which 
have been successively brought forward and again rejected, it will 
be sufficient to mention those which experience has shown to possess 
active powers in this respect, and which are now relied on as un- 
questionable disinfecting agents. The nitrous acid vapours have 
been much employed for disinfecting ships and houses in which con- 
tagion has been found to exist. Such was the evidence brought for- 
ward of the efficacy of the nitrous acid fumes in purifying infected 
places and fomites, that the British parliament voted a national 
donation of five thousand pounds to Dr. Carmichael Smith for the 
discovery. This vapour is readily obtained by mixing with powdered 
nitre, in a cup, a little of sulphuric acid, and applying gentle heat with 
a lamp. 

At present, however, chlorine, and the chlorides of lime and soda, 
are regarded as decidedly the best disinfecting agents we possess. 
M. Labarraque's disinfecting soda liqtcid is a compound of soda and 
chlorine, and its efficacy in destroying infectious matter has been 
conclusively demonstrated. " It is now much used in removing the 
offensive odour arising from drains, sewers, or all kinds of animal 
matter in a state of putrefaction. Bodies disinterred for the purpose 
of judicial inquiry, or parts of the body advanced in putrefaction, may, 
by its means be rendered fit for examination ; and it is employed in 
surgical practice for destroying the fetor of malignant ulcers. Clothes 
worn by persons during pestilential diseases, are disinfected by being 
washed with this compound. It is also used in fumigating the cham- 
bers of the sick, for the disengagement of the chlorine is so gradual, 
that it does not prove injurious or annoying to the patient. In all 
these instances chlorine appears actually to decompose the noxious 
exhalations by uniting with the elements of which they consist, and 
especially with hydrogen." 

" Pure chloride of soda is easily prepared by transmitting to satura- 
tion a current of chlorine gas into a cold and rather dilute solution of 
caustic soda. In preparing the disinfecting liquid of Labarraque, it is 
necessary to be exact in the proportion of the ingredients employed. 
The quantity used by Mr. Faraday, founded on the directions of Labar- 
raque, are as follows: Dissolve 2800 grains of crystallized carbonate 
of soda in 1-28 pints of wafer, and through the solution contained in 
a Wolf's apparatus, transmit the chlorine" evolved from a mixture of 
967 grains of sea-salt and 750 grains of peroxide of manganese when 
acted on by 967 grains of sulphuric acid diluted with 750 grains of 
water."* 

* Turner's Elements of Chemistry. 



GENERAL COURSE, &C., OF FEVER. 73 



CHAPTER III. 

OF THE GENERAL COURSE, TYPE, AND STAGES OF FEVER. 

The series of phenomena which intervene between the commence- 
ment of a fever, and its termination in convalescence, constitutes what 
is technically called its course. The course of a fever is either i?iler- 
inittins;, remitting, or continued, according as its phenomena inter- 
mit, or remit, or are continuous. 

The series of phenomena which constitute the course of a fever, may- 
be divided into six periods or stages: viz., the forming, the cold, the 
hot, the critical, the declining, and the convalescing periods. 

It should be observed, however, that these stages are not always 
distinctly marked, in violent and continuous forms of fever, although 
very {e^sr fevers occur in which the primary stage of oppression, the 
* stage of excitement, and the period of declension, may not be distinctly 
observed. The febrile paroxysm of an intermitting fever offers the 
most distinct exemplification of the successive changes or stages which 
occur in the course of a fever. 

1. The ybrmjVi^ stage — the stadium prodromorum includes the 
period which intervenes between the first impressions of the febrific 
cause, and the actual commencement of the febrile phenomena. This 
period is characterized by a variety of feelings or sensations, which, 
though manifesting a deviation from the healthy condition of the sys- 
tem, do not constitute any definite state of disease. These constitute 
the premonitory/ symptoms. Their duration is very various; and 
in some instances, though very rarely, they are entirely absent — the 
disease making its attack at once, without any previous manifestations 
of its approach. This is most apt to occur in fevers of very vigorous 
reaction, and in such as are of a malignant character. The longer or 
shorter duration of the premonitory stage depends, however, probably 
as much on the different powers of vital resistance as on the differ- 
ence in the degree of concentration or activity of the remote febrific 
cause. The whole train of premonitory symptoms may be regarded 
as the result of the struggle between the vital powers and the febrific 
cause. If the cause be feeble, and the vital resistance great, its first 
impressions may give rise to some unusual or unpleasant sensations, 
until the system finally triumphs over its influence, and disease be 
obviated. When the relative powers of the cause and the vital re- 
sistance are more nearly balanced, the struggle between them may be 
prolonged, until the latter yield and disease be developed; and where 
the system resists feebly, whilst the febrific cause acts with energy, 
the contest will probably be short, and the fever occur suddenly, with 
violent symptoms. There exists, nevertheless, in almost every febrific 



74 GENERAL COURSE, &C., OF FEVER. 

cause, a natural tendency to produce some peculiar premonitory symp- 
toms, although the general and most conspicuous of these phenomena 
are pretty nearly the same in almost every form of febrile disease. In 
general, those fevers which are apt to run through a protracted course, 
have a much longer train of premonitory symptoms than such as are 
violent and of short duration. Thus, the premonitory period is almost 
uniformly much more protracted in typhus and typhoid than in the 
synochal fevers. 

The following are among the most common symptoms of this 
initial period of febrile affections ; loss of appetite ; disturbed sleep ; 
yawning, stretching, lassitude, wandering pains in the limbs and 
back; an impleasant sensation in the stomach; a harsh and dry skin, 
irregularity of the bowels; a general feeling of mal-aise ; nausea; 
eructations ; interruptions of the ordinary habits and appetites ; fret- 
fulness; discontent; slight headache; slight creeping sensations of 
cold; the drying up of old sores ; tremors of the extremities; changed 
expression of the countenance ; giddiness ; and perhaps some other 
slight deviations from a state of perfect health, or the ordinary habits 
and feelings of the individual. 

If we examine the symptoms of this stage in the usual order in 
which they occur, we will perceive that the nervous system is the 
first that suffers ; this is manifested by the lassitude, languor and 
slight transient pains, which usher in this stage. Next, the digestive 
organs are brought into a state of slight suffering ; and finally the 
skin. The heart and arteries appear to be the last organs which are 
brought into morbid action in the development of fever. 

2. The cold stage — Nearly all fevers commence with more or 
less sensation of chilliness. The feeling of cold is not always at- 
tended with an actual subduction of sensible temperature. In some 
instances the skin of the patient feels warm to the touch, whilst he 
is shivering under the severest sensations of cold. It is manifest, 
therefore, that in such cases, the feeling of cold depends in reality on 
an altered or morbid condition of the sensibility of the skin, in conse- 
quence of which its power oi perceiviiig (if I may use the expression) 
the ordinary degree of animal temperature is diminished. In most 
instances of febrile chills, however, there occurs an actual reduction 
of the temperature of the surface, especially of the hands and feet.— 
Not unfrequently these parts feel quite cold to the touch of a healthy 
person, whilst the surface of the trunk and the forehead are of the 
natural temperature, and sometimes apparently even higher; al- 
though the sensation of chilliness experienced by the patient will be 
diffused throughout his whole system. The chills are attended with 
a pale, contracted, and dry state of the surface ; the volume of the 
body is diminished ; the respiration confined, irregular, anxious, and 
oppressed, attended frequently with a short dry couo^h; the head 
feels confused ; the tongue is dry, attended sometimes with great 
thirst; the pulse becomes extremely small, frequent, and feeble; 
nausea often occurs, and sometimes vomiting. The sense of chilli- 
ness is usually diffused over the whole body ; though in some in- 
stances, it is partial, and occasionally, limited to a small part of the 



GENERAL COURSE, &C., OF FEVER. 75 

body. In general, the more violent the chills are, the more vigorous 
will be the subsequent arterial reaction. As the cold stage gradually 
subsides, the arterial reaction regularly rises, until chilliness has wholly 
gone oti', and the disease has entered into the — 

3. Third, or hot stage. — This stage is characterized by what may 
be termed the essential phenomena of fever : viz., augmented heat, 
and a return of the natural fullness and colour of the surface ; flushed 
countenance ; a full, quick, frequent and vigorous, or a small, tense, 
quick and frequent pulse ; throbbing pain in the head : eyes promi- 
nent and sensible to the light ; a dry and hot skin ; urine scanty and 
high-coloured ; continued wakefulness, &c. These symptoms, with 
more or less intensity, continue for a longer or shorter period, until 
the acme of the febrile condition has arrived at the period when — 

4. Crisis svpervenes. By crisis is understood, in the most gene- 
ral acceptation of the term, that period in the course of a fever at 
which it has arrived at its highest point, and a determination either 
to a fatal or favourable issue takes place ; and by which, therefore, 
the fate of the patient is determined. The period during which this 
decision occurs, is necessarily always short ; and is almost universally 
attended with some evacuation. The most common critical evacua- 
tion of a simple febrile paroxysm, consists of a very greatly increased 
flow of perspiratio7i, and hence the subsequent period during which 
this evacuation is continued, is called the sweating stage, but which 
I would call — 

5. The stage of declension — stadium decrementi morbi. — This 
stage may be considered as commencing immediately after the favour- 
able crisis has taken place. In the rapid, continued fevers, and in a 
single paroxysm of an intermittent, one crisis only occurs ; but in 
by far the greater number of protracted, and especially in remitting 
fevers, the crises continue to recur through the whole period of de- 
clension at every tertian exacerbation, until the disease is finally 
subdued. The duration of this stage is extremely various. In gene- 
ral, the period of declension will be pretty nearly in proportion to 
the period occupied in the progress of the fever to its acme. 

The space of time which is occupied by one paroxysm of a fever 
and its succeeding intermission, or which intervenes between the 
regular periodical exacerbations of fever not paroxysmal, is called 
tlie revolution of a fever. The revolutions of fevers are various in 
point of duration ; some fevers completing theirs in twenty-four 
hours, others in forty-eight, whilst others require seventy-two, and 
some even ninety-six hours. The form which a fever assumes, in 
this respect, is called its type; so that a fever which occupies twen- 
ty-four liours from the commencement of one paroxysm to another, is 
said to be of the quotidian type ; whilst one which revolves every 
forty-eight hours, is of the tertian type ; and when this period is ex- 
tended to seventy-two hours, the fever is of the quartan type; and 
a period of ninety-six hours constitutes the quintan type. The 
quotidian, tlie tertian and the quartan types constitute the three 
j)rincipal and primary types of fevers; all of which are, however, 
subject to modifications which may readily mislead the careless ob» 



76 GENERAL COURSE, &C., OF FEVER. 

server, so as to confound them, or mistake one for the other, especially 
the quotidian and the tertian. , 

It has been observed, that in fevers of the quotidian type, the pa- 
roxysms generally come on in the morning—^ circumstance, which 
has been almost invariably verified in my own experience, and which 
is, indeed, so constant, that CuUen was induced to notice it in his defi- 
nition of a quotidian. Tertians commonly come on towards noon ; 
but they are much less regular, in this respect, than fevers of the pre- 
ceding type. Two simple tertians sometimes go on cotemporaneously 
in the same patient ; so that, instead of the paroxysms recurring only 
every other day, they occur daily, as in a quotidian. These cases are 
called double tertians, and are distinguished from quotidians by the 
paroxysms of the alternate days being similar in relation to the pre- 
cise time of their occurrence, grade of violence, duration, and other 
circumstances. Thus the paroxysms on the odd days will perhaps 
recur at 9 o'clock in the forenoon, whilst those which happen on the 
even days will come on at 2 or 3 o'clock in the afternoon, so that, 
although each day has its paroxysms, the fever cannot be properly 
considered as a quotidian, but the cotemporaneous progress of two 
simple tertians, the one having commenced a day sooner than the 
other. Fevers, however, rarely assume the double tertian type from 
their commencement. They usually begin and continue for some 
time in the simple tertian type — the duplication occurring afterwards; 
and when the type thus becomes doubled, the new or accessory pa- 
roxysms are generally considerably milder than those of the original 
or simple tertian. It is asserted, that a double tertian seldom termi- 
nates without first assuming the single tertian type — the accessory or 
weaker paroxysm disappearing first.* 

There are other varieties of double tertians, mentioned by the older 
writers, such as the tertiana duplicata, in which two paroxysms 
occur every second day, and none on the intervening one ; the hxmi- 
tritsetis of the ancients, in which a paroxysm occurs daily, the inter- 
missions or remissions between the first and second, the third and 
fourth, being much more prolonged than those which occur between 
the second and third, the fourth and fifth, &c. Authors also mention 
a triple tertian — tertiana triplex. 

The quartan type, also, has been known to assume similar modifi- 
cations. Double and triple quartans are mentioned in the books: 
as well as other anomalous varieties of this affection. 

Before I proceed to the consideration of the particular fornrisof 
fever, it will be proper to say something concerning crisis or crili- 
cat days — a subject which, though but little regarded at the present 
day, appears to me entirely worthy of attention. It may, I think, be 
assumed as a safe principle, that doctrines or sentiment's concerning 
facts which are objects of mere observation and experience, cannot 
be wholly erroneous or illusory, after having obtained the ent'ire con- 
fidence, through a series of more than twenty centuries of a vast 
number of as accurate and devoted observers of nature as' have ever 

* Richter's Specielle Therapie. \o\. \, 



GENERAL COURSE, &C , OF FEVER, 77 

adorned oar profession. Without professing a belief in the correct- 
ness of the doctrine of crisis as it was taught by the ancients, and by- 
many of the moderns, we may yet admit, on good grounds, it is con- 
ceived, that there exists a natural tendency in the operations of the 
animal economy, whether in a state of health or disease, to certain 
periodical fluctuations, which, under particular circumstances, mani- 
fest themselves in a way sufficiently conspicuous to exhibit an obvious 
revolution in the increase and declension of the morbid actions of 
the animal system. It was early observed, that there are certain 
regular periods in the course of many febrile affections, at which 
prominent changes are wont to occur, preceded generally by a mani- 
fest aggravation of the symptoms, and followed or attended by certain 
evacuations. These evacuations, from their being almost always 
followed by an obvious abatement in the symptoms, were called criti- 
cal, and were thought to consist of noxious or febrific matters, thus 
thrust out of the system by the sanative powers of nature. Fever 
was supposed to be nothing else than an effort of nature to prepare 
and cast out of the system the morbific materials which disturbed the 
regular actions of the animal economy, and that the amendment 
which ensued was the immediate consequence of such eliminations 
of morbific matter. At the present day it is, however, more correctly 
maintained that these critical discharges are the effects, and not the 
causes of the melioration which occurs about the periods at which 
they take place ; and that they are to be viewed rather as the first 
manifestations of a favourable change in the condition of the system 
than as the immediate causes of such a change. That this is the cor- 
rect view in relation to the nature of such discharges, there can, in- 
deed, exist no doubt; but this view of the subject does not deprive it 
of its importance, and directs our attention rather to the periodical 
exacerbations and inherent tendencies in these maladies to terminate 
their course at one period in preference to another, than merely to 
the evacuations which are apt to supervene at such times. In no 
forms of fever, perhaps, are these tendencies to terminate at a certain 
fixed period more frequently manifested than in intermittents. There 
appears, in these fevers, a tendency to a septenary revolution, which 
I have often seen verified in the most unequivocal manner. If an 
ague of the quotidian type be suffered to run on until it terminates 
spontaneously, the termination will almost universally occur, if it 
occur at all, either after the seventh, fourteenth, or twenty-first parox- 
ysms ; and I have repeatedly found, that febrifuge remedies, exhibited 
immediately after these septenary periods, will arrest it with more 
certainty, and with much less liability to relapse, than when employed 
during any of the intervening intermissions. From the same inhe- 
rent tendency, the relapses which are so common in this disease will, 
in a vast majority of instances, occur about the septenary periods 
from the time of the last paroxysm, and most commonly about the 
eighth or fourteenth, and sometimes for several periods about the 
twentieth day — (Jackson,* Sprengle.t) 

* On the Diseases of Jamaica. 

t Handbuch der Pathologie, Band. ii. p. 171. 



78 GENERAL COURSE, &C., OF FEVER. 

Observation has shown, that tlie crises of fevers happen almost 
uniformly on the odd days, reckoning from the commencement oi tne 
malady. According to the observations of Hippocrates, tne crises 
occur in conformity to the tertian type, until the filth crisis, or tne 
eleventh day of the fever, after which they observe the quartan tjrpe, 
occurring only every fourth day. It must be observed, however, that 
these evacuations do not occur exclusively on the days just mdicated, 
for they are sometimes, though rarely, found to happen on the inter- 
vening days. Galen supposed, that when the crisis falls on any other 
than a critical day, the fever has been diverted from its natural tend- 
ency by the accidental occurrence of irritation in some part of the 
system. Galen divided the critical days into \he perfect, the secondary, 
and the intercurrent. The perfect are those which happen on the 
seventh, fourteenth, twenty-first, and twenty-eighth days. The second- 
ary, or less perfect, occur on the intermediate day between each 
perfect or septenary crisis— namely, the fourth, eleventh, eighteenth, 
twenty-fifth, &c., days. If, for example, it was observed that a slight 
deposit in the urine, or a moderate flow of sweat took place on the 
eleventh day, it was regarded as an indication of a more perfect crisis 
on the fourteenth day. The intercurrent crises occur on the remaining 
odd days— that is, on the fifth, ninth, thirteenth, &c. Such are the prin- 
cipal points in the doctrine of crisis, as it was taught by the ancients, 
and more especially by Hippocrates, and his commentator Galen. 
No one at the present day, however, pretends to have observed the 
many minute distinctions and phenomena which are embraced in 
the ancient doctrine on this subject ; indeed, there are very few who 
regard it as at all worth any attention ; and the profession seem long 
since to have thrown it into the common mass of error and miscon- 
ception, which has been formed out of the wrecks of former systems 
and doctrines. However antiquated it may appear, at the present 
advanced stage of our science, to profess some faith in the general 
correctness of this doctrine, I cannot, at the risk even of being set 
down as a cherisher of obsolete and exploded sentiments, divest my- 
self of the conviction, that among much that is erroneous and absurd 
in this doctrine, there are important and fundamental truths which 
ought not to be carelessly rejected. 

In order to understand the nature of crisis, every fever must be 
considered as having a tendency to some one of the principal tt/pes 
mentioned above. A simple tertian intermittent may be regarded 
as the elementary type of fever. In fevers of this type, an exacer- 
bation or paroxysm, and a crisis, will occur on every odd day ; and if 
we consider a continued fever as made up of tertian paroxysms pro- 
longed and running into each other, or as possessing a natural, though 
countervailed tendency to the elementary or tertian type, there will, 
in like manner, occur more or less considerable tertian exacerbations, 
with their accompanying discharges. From what has already been 
said concerning the manifestseptenary movements of intermittents, the 
tendency of continued fevers to terminate on the fourteenth or twenty- 
first days, which can scarcely be denied^ would seem to be in conform- 



GENERAL COURSE, &C., OF FEVER. 79 

ity with an original law of the animal economy, under a state of 
febrile excitement. 

The evacuations which usually accompany the crisis of fever are, 
— I. haemorrhages; 2. a flow of sweat; 3. an increase or changed 
character of urine ; and 4. diarrhoea. Critical haemorrhages are gene- 
rally attended with an increased action of the heart and arteries, and 
often with a manifest determination to, and congestion in, the part 
from which the discharge occurs. They must be regarded as mere 
manifestations of a previous change in the system, and hence this 
critical kind of evacuation cannot be substituted by an artificial ab- 
straction of blood; since, although blood may be abstracted, the pecu- 
liar action of the solids, which constitutes the actual crisis or change 
to a favourable tendency, cannot be thus produced. Crisis, by 
haemorrhage, is generally confined to inflammatory fever; or, more 
correctly speaking, to fevers attended with an increased activity and 
action of the heart and arteries. Critical haemorrhages most comr 
monly proceed from the nose, and, according to the observations of 
many of the older writers, are frequently preceded by the dicrotus 
pulse, in which two distinct wave-like beats occur during each dias- 
tole of the artery. Immediately before the irruption of the blood the 
carotids beat strongly, the face becomes flushed, sparks appear before 
the eyes, the eyes are red and suff"used with tears ; and, in some in- 
stances, frequent sneezing, and a thin watery discharge from the nos- 
trils occur just before the haemorrhage appears. Critical sanguineous 
discharges have also been known to occur from the uterus, the rec- 
tum, and sometimes, though very rarely, from the stomach, and even 
from external parts. 

Crisis by an increased flow oi perspiration is by no means uncom- 
mon. Catarrhal and rheumatic fevers are more apt to terminate by 
this mode of crisis than any other forms of febrile afl^ction. This 
discharge is not, however, to be regarded as indicative of a favourable 
change in the malady, unless it be generally diffused over the whole 
surface, and especially, unless it be attended with a turbid state of 
the urine, or a copious sediment in this latter evacuation. The sur- 
face should, moreover, be soft, and of a natural temperature— that is, 
not cold and clammy. 

Crisis by urine, independent of perspiration, is a very uncommon 
mode of termination in febrile complaints. A critical urine derives 
its favourable character not so much from the mere quantity of the 
evacuation, as from its appearances and the materials with which it 
is impregnated or mixed. For inspection, the urine which is evacuated 
at the termination of a paroxysm, or in the morning, ought to be 
chosen. In a truly critical urine there may be seen at first a cloud 
floating in the upper part of the vessel, then a globular body of mu- 
cus about the middle, and a sediment at the bottom.* So universal 

* Vogel Richter, Hufeland. I have frequently noticed these appearances in 
the urine, evacuated after a paroxysm of intermitting fever ; and I am vrell satis- 
fied that it is a common occurrence in the urine discharged soon after fevers have 
commenced to decline. 



80 GENERAL DIAGNOSIS. 

is the concurrence of a critical urine, and a general "^"'^^^^g^gj^jj^^n 
skin, that these two evacuations may be considered as e . y 
connected. , fh^eo i 

A critical discharge from the bowels is less common than tnose i 
have already mentioned. It occurs most frequently m bUious levers, 
and in such febrile affections as are attended with some visceral dis- 
ease within the abdomen. These discharges do not however occur 
as the others do, in the acme or exacerbations of the lever, but anring 
the periods of remission. They are generally very copious 1 he 
signs of an approaching crisis by diarrhoea are a pecu lar tremblmg ot 
the under lip ; stammering speech ; a full and wave-like pulse ; pam 
and rumbling noise in the bowels ; discharge of wind ; a moist tongue ; 
itching in the nose ; paucity of urine, &c. (Richter.) 



CHAPTER IV. 

ON GENERAL DIAGNOSIS. 

Nothing so much distinguishes the experienced and truly well- 
qualified physician from the mere haphazard recipe-doctor, and rou- 
tinist, as the ability to estimate correctly the import of symptoms ; 
to trace their various relations with each other, and to determine 
from them the seat, nature, and extent of maladies. The number of 
those who are remarkable for accuracy in diagnosis, is always very 
small •, for eminent proficiency in this respect can be obtained only 
by persevering observation and study, aided by a minute and com- 
prehensive acquaintance with physiology and pathology. 

Diagnosis embraces a much wider range of inquiry than that which 
is presented by the actual phenomena of diseases. It is not alone 
from morbid symptoms that the intimate character and tendency of 
diseases can always be satisfactorily determined. Age, sex, moral 
and physical temperament, climate, occupation, habit of living, cor- 
poreal conformation, previous diseases, hereditary predisposition, and 
the character of the predisposing and exciting causes, often afibrd 
important aid in the formation of a correct diagnosis. In chronic 
diseases, especially, the light which may be obtained from circum- 
stances of this kind, is frequently of the utmost importance in this 
respect. 

The manner in which patients are examined, also, has a direct and 
important bearing on diagnosis. A confused, desultory, or imme- 
thodical mode of investigating the symptoms of diseases, and the 
various circumstances which may have contributed to determine their 
character, seldom leads to a clear and precise diagnosis. Indeed the 
manner in which a physician examines his patients affords no incon- 
siderable criterion for judging of his practical qualifications. Method, 



GENERAL DIAGNOSIS. 81 

regularity and deliberation, in this respect, are almost always asso- 
ciated with skill in diagnosis, and consequently in the treatment of 
diseases. 

The first objects which strike the attention of the physician, on ap- 
proaching a patient, are his countenance, attitude, ?notions and voice. 
It is natural, therefore, to commence the examination with these symp- 
toms. In many instances these external conditions of the patient 
afford very important information as to the nature and seat of mala- 
dies; and in no case, perhaps, can they be entirely neglected without 
losing very useful snggestions in relation to the diagnosis. 

The countenance should be deliberately and closely examined, and 
its deviations from the healthy aspect and expression noticed. Many 
diseases are attended with expressions of countenance so peculiar 
and striking, that they may be at once recognized by the observant 
and experienced physician. The attitude, motion?, and external 
condition of the patient's body, must, also, be particularly noticed. 
The degree of emaciation — the colour and condition of the skin, and 
the general physical habit and conformation, should be observed. 
The various regions of the body shonld be carefully examined, more 
especially in diseases of a chronic and obscure character. In some 
general maladies, such as scurvy, syphilis, scrofula, &c., the ecchymo- 
ses, glandular indurations, eruptions, blotches, exostoses, nodes, &c., 
afford important diagnostic evidence. Old cicatrices, too, merit par- 
ticular attention ; particularly when seated along the neck and in the 
groins. The former almost always indicate a scrofulous diathesis, 
whilst the latter afford good grounds for suspecting the existence of 
a syphilitic taint. The existing disease, for which the physician is 
called to prescribe, may have a very intimate connection with one or 
the other of these maladies or constitutional taints ; and as patients 
are apt to neglect giving proper information on this subject, or even 
seek to conceal the fact of their having been affected with such a 
disease, these old marks or cicatrices are sometimes of essential ser- 
vice, to a full and satisfactory investigation of the case under exami- 
nation. 

Having attended to these external circumstances, the examination 
of the case must be pursued, by interrogating the patient. The man- 
ner in which the examination is conducted, is of great importance. 
A careless, irregular and hurried, or a peevish, fretful and impatient 
manner of examining, seldom fails to lessen the good will and confi- 
dence of the patient for his medical attendant ; whilst a mild, deliberate, 
earnest and interested deportment, not only gains the patient's confi- 
dence and respect, but contributes very materially to a full develop- 
ment and correct understanding of the nature of the malady. The 
questions should always be proposed in terms perfectly intelligible to 
the patient ; and when there is reason to doubt whether the interroga- 
tory has been correctly apprehended, it should be repeated in different 
terms. The employment of a pompous and technical phraseology, is 
more apt to excite the contempt and distrust of intelligent patients, 
than to draw forth correct and satisfactory responses. 

It is of considerable consequence, also, to follow a determined and 

VOL. I. 6 



82 GENERAL DIAGNOSIS. 

regular order in the questions put to the patient. Without a proper 
attention to order or method in this respect, important questions are 
apt to be forgotten, and some which have ah'eady been proposed and 
answered, uselessly repeated. Although the interrogatories should be 
sufficiently numerous and varied to obtain a full view of the symp- 
toms and feelings of the patient, and of the circumstances which may 
have contributed to the development and modification of the disease, 
yet trivial and irrelevant questions should be avoided. 

The following order of inquiry appears to me the most natural and 
advantageous. 1. Ascertain the a^e, occupation and place of resi- 
dence of the patient. In many instances, indeed, these circumstances, 
more especially the last, can have no useful bearing on the diagnosis; 
but this is by no means always the case ; for, in some cases, very 
important diagnostic and practical suggestions may be obtained from 
a careful consideration of these facts. 2. Inquire next, at what time 
the disease commenced; whether it came on gradually or suddenly; 
whether the existing symptoms differ from those which attended the 
disease at an earlier period ; whether the progress of the complaint is 
continuous or paroxysmal, constant or occasional, uniform or attended 
with exacerbations and remissions ; whether, in the course of the dis- 
ease, new symptoms have supervened, and former ones disappeared, 
and whether the permanent symptoms have increased much in vio- 
lence since the commencement of the complaint. Correct information 
in relation to these circumstances is often indispensable to a satisfactory 
diagnosis. " In many instances, indeed, the succession and general 
progress of the symptoms, afford more useful data for the formation 
of a correct diagnosis, than a consideration of the symptoms existing 
at the time of examination. Unfortunately, the majority of patients 
are incapable of giving a proper account of the early symptoms and 
progress of their maladies ; and the physician is thus frequently de-^ 
prived of the light which a correct and circumstantial exposition of 
the preceding symptoms and course of the case might afford." 3. The 
patient should now be asked whether he experiences any pain, and 
if so, in what part of the body. He should be directed to place his 
hands on the region in which the pain is felt ; for patients are apt to 
express themselves very vaguely and incorrectly in relation to the 
part in which the pain is seated. Thus, we are often told that pain is 
felt in the stomach, yet when the region is pointed out with the hand, 
it is, perhaps, found to be seated in the lower part of the abdomen, 
or within the chest. Inquiry must also be made whether the pain be 
acute or darting ; dull and aching; stinging or burning, or throbbing; 
—whether it be deep seated or superficial, continuous or intermitting, 
wandering or fixed, transient or protracted ; and, if intermitting or 
paroxysmal, whether its occurrence be periodical or at irregular and 
uncertain intervals. Pressure should be made on the part^in which 
the pain is located, and its effects carefully noticed ; and it is particu- 
larly important to ascertain whether there is soreness or tenderness 
to pressure in certain organs or regions of the body, more especially 
in the various regions of the abdomen ; although the patient may not 
complain of any pain in these parts, when undisturbed by pressure. 



GENERAL DIAGNOSIS. S3 

It will also be proper to ascertain whether the afl'ected parts are 
swollen, discoloured, or in any other way changed from their normal 
or healthy appearance and conformation. 4. The state of the san-. 
guiferons system should next be inquired into. The pulse must be 
attentively and deliberately examined ; and in doing this, attention 
must be paid to the circumstance, that the pulse of an infant, during 
the first three or four weeks after birth, beats betweenl20 and 130 
strokes in a minute ; and that its natural frequency undergoes a gra- 
dual reduction as age advances, until about the age of puberty, when 
it arrives at the standard of a healthy adult pulse, namely, from about 
72 to 80 pulsations in a minute. It should be observed, too, that 
climate, the time of day, corporeal exertion, position of the body, 
and mental emotions or exercise, exert, often, a very material influ- 
ence on the state of the pulse. In the morning, whether in health or 
disease, the pulse is generally considerably slower and softer than after 
dinner or towards evening. In feeble and nervous individuals, we 
often find the pulse much more frequent when they are standing up, 
than when in a recumbent position. In this case, the muscular exer- 
tion required to maintain the erect posture operates on the circulation 
in the same way as exercise, and therefore accelerates the action of 
the heart and arteries. Nothing, however, is so apt to give rise to a 
wrong estimate of the state of the pulse, as that mental excitement 
and flurry which feeble and irritable patients are apt to experience on 
the entrance of the physician into the sick chamber. I have fre- 
quently found adiiference of more than twenty pulsations in a minute, 
between an examination made immediately after entering the room, 
and a second one, some ten or fifteen minutes • afterwards. It is 
therefore an important rule, to delay examining the pulse, until the 
agitation of the patient's mind has subsided. By introduciug the 
examination with some encouraging and cheering remarks, and pro- 
ceeding in the order already mentioned, there can seldom be any risk 
of mistake, from this source, as to the actual state of the pulse. In 
examining the pulse, the patient's arm should be held in a horizontal 
and semiflexed position. Two or three fingers must be applied to 
the artery, and the pressure gradually varied in force, in order to form 
a correct estimate of the degree of tension, vigour, hardness or com- 
pressibility of the pulse. Thirty or forty pulsations, at least, ought to 
be felt before the fingers are taken off. It is not uncommon in certain 
obscure cerebral affections, to find an intermission in the pulsations, 
at intervals of from ten to thirty and even a greater number of beats. 
A transient examination, may not only fail to detect such intermis- 
sions, but is in general, quite insufficient for obtaining a satisfactory 
view of the precise character of the pulse. All conversation should 
be forbidden, both on the part of the patient and the attendants. In 
certain affections, and when the system is under the influence of cer- 
tain remedial agents, (as digitalis,) it will be proper to examine the 
pulse in different positions of the patient's body ; namely, in the re- 
cumbent, sitting and standing postures. This is particularly useful in 
certain organic affections of the heart. There is, perhaps no depart- 
ment of symptomatology in which a high degree of proficiency is 



84 GENERAL DIAGNOSIS. 

SO seldom met with among physicians, as that which relates to the 
morbid manifestations of the pulse. Many seem to think that tne 
only modifications of the pulse, which are worthy of particular atten- 
tion, relate to its frequency, fulness, hardness, tension a"J.^"^S"'^'^'"'^y- 
There are various other states of the pulse, however, which though 
not easily described, communicate to the experienced and diligent 
observer, definite and important views concerning the pathological 
conditions with which they are associated. The ancients, and even 
some of the moderns, undoubtedly carried their refinements and pre- 
tensions, in relation to this subject, to an absurd extent. It is not 
improbable, however, that among much useless rubbish, which in the 
progress of our science, has been swept away concerning the organic 
pulses, as they were called, some valuable facts and principles were 
included, which might be advantageously revived. Be this as it may, 
a faithful and continued attention to the morbid states of the pulse, 
with diligent and well directed efforts to obtain definite conceptions of 
its various modifications, and to associate them with their respective 
pathological conditions, will, in general, result in the acquirement of 
a precision and readiness of discrimination, and accuracy of diagnostic 
application, which few who have not made the pulse a particular 
object of study and observation can well conceive or credit. 5. Hav- 
ing ascertained the condition of the pulse, the attention should be 
particularly directed to the organ or part in which the primary or 
essential malady appears to be seated. Inquiry must next be directed 
to those structures or organs which are known to hold the most inti- 
mate sympathetic relations with the part or organs principally affected. 
Thus, if the patient complains of much pain, or of other unpleasant 
sensations in the head, after having obtained a circumstantial account 
of the cephalic symptoms, the examination should be directed to the 
state of the alimentary canal. Again, if there is a fixed pain in the 
lumbar region, the important question whether the pain be located in 
the kidneys, or in some neighbouring structure, may, in general, be 
readily settled, by attending to the condition of those organs with 
which the kidneys sympathize most strongly ; namely, the stomach, 
the ureters, and the testes. If there is a retraction of the testes, pains 
shooting down along the ureters, with nausea and vomiting, the 
fact of its being a renal affection may be regarded as sufficiently as- 
certained. 

In the investigation of diseases, it should be recollected that the 
prominent and most annoying symptoms are by no means always 
located in the part where the primary and actual malady is seated. 
A slight inflammatory affection at the origin of a spinal nerve, not 
unfrequently manifests itself by severe and protracted pain in some 
remote part of the body; as in the chest, the abdomen, or the inferior 
extremities. When, therefore, a fixed pain is unattended with any 
other manifestations of disease in the part; when there is neither 
inflammation, nor soreness or tenderness to pressure, we may pre- 
sume, that the primary affection, upon which the disease depends, 
is located in some other part of the body ; and on proper inquiry, 
it will perhaps be found to be seated at the spinal orio-in of these 



GENERAL DIAGNOSIS. 85 

nerves, which are distributed to the structure in which the pain is 
felt. To ascertain whether this be the case, firm pressure must be 
made on each of the spinous processes of the vertebral column. If, 
in passing successively from one spinous process to another, the 
patient flinches and complains of pain in one or more vertebrae ; it 
may be inferred that the source of the painful affection is probably 
seated at the root of the nerves which pass out from that part of the 
spine. 

Many diseases, which appear to be of a general character, con- 
sisting seemingly in mere functional derangement, are nevertheless 
intimately connected with obscure and frequently very serious local 
affections. The diagnosis, in such cases, is generally extremely 
difficult. In some instances, a probable opinion, as to the existence, 
seat and character of such obscure and local affections, can be formed 
only by taking into view the effects of certain remedies and the na- 
ture of the exciting causes, in connection with the actual symptoms 
and general progress of the malady. Inflammation of some portion 
of the mucous membrane of the alimentary canal, often attends 
general diseases with manifestations so slight and inconspicuous, as 
sometimes to escape the notice of even attentive observers. In rela- 
tion to the diagnosis on this point, especial attention must be paid, in 
the examination of the symptoms, to the appearance of the tongue ; 
the condition of the alvine evacuations ; the effects of irritating in- 
gesta ; the effects of firm pressure on different parts of the abdomen, 
with regard to the sensations which it excites ; the state of the skin ; 
and if the malady is of a chronic character, the temper and condition 
of the mental faculties. It should be particularly noticed, whether 
the surface of the tongue be red, and of a granular or smooth appear- 
ance — whether irritating and solid ingesta give rise to pain and 
distress in the stomach, or tormina in the bowels; whether pressure 
on any part of the abdomen gives rise to a pain or a feeling of sore- 
ness ; whether the skin in connection with these symptoms be dry, 
harsh, and contracted, and whether the temper is morose, gloomy, 
taciturn and irritable. The particular appellation of these pheno- 
mena will be fully illustrated in a subsequent part of this chapter. 

I proceed now to the consideration of the particular diagnostic signs 
as presentfd by the countenance, the attitude, the nervous system, 
the alimentary canal, the blood-vessels, the respiratory organs, the 
cuticular surface, the lymphatic system, and the secretions. 

1. The countenance is variously and often strikingly changed by- 
diseases, and affords in many instances, highly important diagnostic 
indications. Hippocrates strongly recommends the study and exam- 
ination of the countenance in disease. His attention, however, was 
directed principally to the prognostic signs, manifested by the coun- 
tenance, and the observations which he has left us, on this subject, 
are among his most valuable contributions to our science. In relation 
to diagnosis, however, we find but few observations in his writings, 
concerning the morbid expressions of the countenance. This point 
has been more particularly attended to in latter times; and although 
there is still much room for profitable inquiry, yet the facts and prin- 



86 GENERAL DIAGNOSIS. 

ciples which have already been established, are sufficiently numerous 
and interesting, to show the importance of attending to the counte- 
nance, as a source of valuable diagnostic information. 

M. Jadelot, physician to the Hbpital des Enfans Troiivees, has 
published some interesting observations on the physiognomical ex- 
pression of certain forms of disease in children. According to his 
observations, there are three principal physiognomical /rai7.9, which, 
in children, are often very conspicuous — each indicating a peculiar 
morbid condition of the system. 

The first consists of a distinct pale or lead coloured streak with 
an appearance of depression, commencing at the greater angle of the 
eye, and terminating a little below the projection formed by the cheek 
bone. This he calls the oculo-zygomatic ^raif. This trait indicates 
disorder of the "cerebro-nervous system." It is strongly marked in 
all those maladies whose primary and principal seat is in the brain 
or on the nerves. It is likewise present whenever the nervous system, 
more especially the brain, participates actively in affections which are 
in the first place located in other structures or organs; but in cases of 
this kind, some other facial trait usually co-exisls, which indicates 
the character of the complication. Thus, for instance, when intestinal 
irritation from worms or other causes, finally occasions hydrocepha- 
lus, epilepsy, &c., the oculo-zygomatic trait will be added to the 
previous physiognomical expression indicative of the intestinal disor- 
der. 

The second trait begins at the upper part of the alse nasi, and em- 
braces, in a semicircle more or less complete, the outer line of the 
orbicularis oris. It is not uncommon to observe, towards the middle 
of the cheek and forming a tangent with this trait, another one which 
in certain faces constitutes the dimple of the cheek. These two traits, 
says M. Jadelot, are referable to similar affections. The first he calls 
nasal, the second genal. This trait, and its accessory, indicate disor- 
der, particularly chronic irritation or inflammation of the alimentary 
canal, and of the abdominal viscera. It is observed in diarrhoea, indi- 
gestion, verminous irritation, &c. 

The third trait begins at the angle of the lips, and is lost on the 
margin of the chin. This is called the labial trait. It seldom forms 
a deep line, being modified by the changes which the neighbouring 
parts undergo. The other traits are more or less deeply marked 
according as the diseases to which they belong are more or less 
severe or protracted in their course. This trait attends diseases of 
the heart and of the respiratory organs, and may almost always be 
observed in cynanchse, carditis, hydro-pericardinm, organic affections 
of the heart, pneumonia, &c, 

M. Salle observes, that at the onset of all severe diseases, the 
inspection of the child's countenance may serve as a useful guide to 
the physician in discovering the organ principally affected. "The 
presence or absence of the oculo-zygomatic trait, in the initial stage of 
the disease, will inform him whether the cerebro-nervous system be 
primarily affected, or whether its supervention be merely the result of 
sympathy." He asserts that at a single glance he has often been 



GENERAL DIAGNOSIS. 87 

enabled to pronounce with confidence the existence of abdominal dis- 
ease, by observing the presence of the nasal trait. It is said to be 
particularly conspicuous in dysentery, and chronic diarrhoea. 

I have, for several years past, attended very carefully to these 
observations of M. Jadelot, and am entirely persuaded that they are 
correct, and of essential service in the diagnosis of certain diseases of 
children. 

In addition to these physiognomical expressions, the singular 
change of countenance which, according to Dr. Wolff,* occurs in chil- 
dren labouring under chronic or sub-acute peritonitis, deserves to be 
mentioned. This writer asserts that in the hydropic stage of this 
affection, " the skin at the root of the nose, immediately between the 
eyes, "acquires a swollen or bloated appearance, by which the gene- 
ral expression of the countenance is strikingly altered. " The parents 
of my patients" he says, " frequently noticed a change in the expres- 
sion of the countenance, without being able to say in what it consisted; 
but as soon as I directed their attention to the tumefaction of the skin 
at the spot mentioned, they agreed with me, that the change in the 
appearance of the child's countenance arose from it, and were sur- 
prised that they had not discovered it themselves." This singular trait, 
he asserts, is one of the most constant and certain diagnostic signs of 
the disease, after serous effusion in the abdomen has commenced. 

Sprengle observes, that chronic disease of the spleen is, almost 
invariably, attended with a remarkable bluish tinge of the tunica 
albuginea. I have verified this observation in several instances. — 
During my term of attendance last winter at the Commercial Hos- 
pital of this place, a patient was brought into the house, labouring 
under some chronic malady. At the first glance of his countenance, 
I noticed the singular blue tinge of the albuginea. I pointed it out 
to the students in attendance, and stated the diagnostic inference 
which, according to the observations of Sprengle, this appearance 
justified — namely, that the patient was labouring under some chronic 
affection of the spleen. This man has since died, and on post-mortem 
examination, the spleen was found very much enlarged, and other- 
wise disordered in its structure. 

Pain, whether from spasm or inflammation, always causes a 
peculiar contraction of the muscles of the countenance. The physiog- 
nomical expression of pain is, indeed, so characteristic that the most 
inexperienced will readily interpret it correctly. An attentive and 
experienced observer may even perceive, in the peculiar contraction 
of the features, in what class of organs, or in what organ, the cause 
of the pain is seated. Thus when the diaphragm is inflamed, the 
pain, from the situation in which it is felt, might be supposed to be 
seated in the stomach, the liver, or the spleen ; but the peculiar grin- 
ning expression of the countenance, [risus sardoniciis,) which attends 
injuries, or inflammation of the diaphragm, indicates, at once, the 
true seat of the disease. 

Pain depending on inflammation of the mucous membrane of the 

* IlufelancVs and Osan's Jour, der Practischen; Heilkunde, May, 1829. 



88 GENERAL DIAGNOSIS. 

alimentary canal, generally gives an expression of gloom, irascibility 
and discontent to the countenance ; and this is more especially the 
case when the stomach and duodenum are affected. When the lungs 
are the seat of painful sensation, there is an expression of great anx- 
iety depicted in the countenance, attended with an unusual expansion 
of the nostrils, during each inspiration. Even, when there is no acute 
pain, in affections of the lungs, this peculiar anxious expression of 
the countenance and expansion of the alae nasi, generally occurs, in 
consequence of the congested condition of these organs impeding the 
respiratory functions. Dr. Marshall Hall observes, that the more 
acute the pain is, in inflammation of the thorax, the more contracted, 
in general, will be the features. When the pain is very severe, the 
alae nasi are acute, and elevated, and the nostrils are strongly con- 
tracted and expanded, by the alternate acts of respiration. In 
addition to this, there is sometimes a vivid flush on the cheeks, termi- 
nating abruptly, and bounded by a very pale streak towards the nose. 
'In great difficulty of breathing, /rom a conges / ed stSile of the lungs, 
the countenance is not only marked by an expression of anxiety, but 
becomes, also, more or less suffused with a dark or livid hue, accom- 
panied with turgidity or fulness. Whenever, therefore, this livid 
appearance, and turgidity of the vessels of the face occur, in diseases 
of the lungs, we may be assured that there exists either great san- 
guineous congestion in these organs, or an effusion of fluid into them. 
This is still more certainly the case, if with these physiognomical 
signs, the surface of the body is rather below the natural tempera- 
ture. 

The countenance peculiar to tubercular phthisis is so striking, 
that even the most careless observers, in general, readily recognize 
it. The delicate paleness of the face ; the circumscribed flush on the 
cheeks in the afternoon ; the pearly whiteness of the tunica albuginea ; 
the quivering motion of the lips and chin in speaking, are well 
known as the invariable and ill-boding attendants of pulmonary con- 
sumption. 

In "inflammation of the abdominal viscera," says Dr. Hall, "at- 
tended with severe pain, the muscles of the face are in a state of 
continued contraction ; the features are unnaturally acute, the fore- 
head is wrinkled, and the brows knit. The nostrils are acute and 
drawn up ; the wrinkles, which pass from them obliquely downwards, 
are deeply marked, the upper lip is drawn upwards, and the under 
one frequently downwards, so as to expose the teeth. The state of 
the features is aggravated on any increase of the pain Irom change 
of position or external pressure. When the abdominal pain arises 
from spasm, the muscles of the face are exceedingly contracted and 
distorted during the paroxysms of pain; but in the intervals of the 
paroxysms, the countenance assumes a calm and placid aspect." 

In organic affections of the heart, the countenance generally ac- 
quires a very peculiar expression. In cases of this kind, the prolabia 
are more or less livid, the face puffy or oedematous, and of a peculiar 
dingy hue, or suffused with a livid flush. This circumstance is 
worthy of notice, in relation to the diagnosis between oraanic affec- 



GENERAL DIAGNOSIS. 89 

tions of the heart, and hydrothorax. In the latter affection, the 
countenance almost always exhibits a pale, or pale livid aspect, in- 
stead of the vivid flush so common in cardiac diseases. (Hall.) 

In the sopo7'ose affections, also, the countenance is variously and 
characteristically affected, and affords important diagnostic indica- 
tions. In the apoplectic attack, the face is generally flushed, or livid, 
and the blood-vessels of the head and neck turgid. The muscles of 
the face are frequently paralytic on one side, so as to destroy the 
natural symmetry of the features, the mouth is drawn towards the 
unaffected side, whilst the eyebrows, nostril, angle of the mouth, and 
cheek of the paralyzed side sink down. The flush and fulness of 
the face do not, however, continue throughout the whole course of 
the disease ; towards the fatal termination of the attack, the counte- 
nance usually becomes pale, and somewhat contracted. In syncope, 
the countenance is pale, shrunk, and covered with a cold perspiration, 
presenting a death-like appearance ; and in that state of insensibility 
which sometimes occurs in hysteria, the countenance is nearly natu- 
ral, both in colom* and expression. In the two latter affections there 
is no unusual sanguineous congestion in the head. The blood is 
accumulated in the lungs and heart, and hence, when recovering 
from the state of insensibility, patients generallv experience a sense of 
great weight and pressure in the chest, more especially in the region 
of the heart. 

Chlorosis is always attended with a very peculiar and characteris- 
tic appearance of the countenance. " The incipient stage is denoted 
by paleness of the cornplexion — an exsanguious state of the pro- 
labia, a slight appearance of tumidity of the face, or fulness of the 
eyelids,'* In some instances, a tinge of green, or of yellow is ob- 
servable in the pallor of the countenance, and the eyelids are of a 
dark lead-coloured hue. " In the confirmed stage of the disease, the 
face is still more pallid ; the prolabia acquire a slight lilac hue, and 
the integuments, in general, a puffy and tumid appearance. In the 
more chronic form of this malady, the countenance exhibits an ap- 
pearance of sailoiv7tess, of squalid or dingy paleness, with a ring of 
darkness occupying the eyelids, extending a little towards the temples 
and cheeks ; and in some instances a similar dark streak surrounds 
the mouth." Dr. Hall observes, that this sallowness or icterodc ap- 
pearance of the countenance, must not be confounded with the differ- 
ent shades of icterus, or bilious tinge. In icterus or jaundice, that is, 
when the discoloration depends on the deposition of bilious matter, 
the tunica albuginea of the eyes, is invariably more deeply tinged 
with yellow, than any other portion of the surface ; whereas, in the 
more id erode, or sallow appearance of the complexion, observed in 
chlorosis, and in some other chronic affections, the eyes do not exhibit 
any distinct tinge of yellow. When, therefore, the countenance of 
a patient presents a yellowish hue, without a similar tinge of the albu- 
ginea, we may conclude, that it does not depend on the presence of 
bilious matter in the circulation, or on biliary derangement. 

In chronic irritation of the bowels, from worms, or other irritating 
substances lodged in the alimentary canal, a remarkable pale tunie- 



90 GENERAL DIAGNOSIS. 

faction of the upper lip frequently occurs, in conneetion with the na- 
sal and ^e;K// traits, mentioned above. This swollen state ot me nps 
is generally but transient in verminous affections. It usually comes 
on at night, during sleep, and seldom continues more tnan two oi 
three days. A somewhat similar swollen state of the upper lip ot en 
occurs in children affected with scrofula ; more especially when the 
disease is principally seated in the mesenteric glands, in cases ot 
tliis kind, however, the tumefaction is much more permanent ; there 
is also more lividity of the prolabia and the cheeks, and the peculiar 
traii mentioned by Jadelot, (the nasal and genal,) are not present 

In inflammation of the arachnoid membrane, the expression of the 
countenance is senerally strikingly characteristic. Besides a general 
expression of surprise, confusion, and discontent which it is iinpossi- 
ble to describe, but which cannot easily be mistaken when once seen 
and contemplated, the most prominent morbid expressions of the 
countenance are those furnished by the eye. According to the ob- 
servations of Martinet and Duchatelet, the pupils are either much 
dilated or contracted; the conjunctiva presents a greater or less de- 
gree of redness ; and when the inflammation has made considerable 
progress, and is about terminating in effusion, or structural lesion of 
the brain, there is squinting, and constant rolling of the eyes, or they 
are turned upwards so as to conceal the cornea. In nearly all instan- 
ces, the upper eyelids become paralyzed, so that the patient, in en- 
deavouring to look at any object, is unable to raise the lids by their 
proper muscles, and is therefore obliged to draw them upwards, toge- 
ther with the integuments of the forehead, by the contraction of the 
occipito-frontalis muscle.* Martinet observes, that these latter symp- 
toms, namely, the turning up of the eyes and paralysis of the upper 
eyelids, are the most constant symptoms manifested by the counte- 
nance in this disease. Whytt and Camper also declare that they are 
among the most certain diagnostic signs of this dangerous malady. 

Sprengle (Handbuch der Semiotik) says, that the appearance of the 
tunica albuginea affords an excellent diagnostic sign between scarla- 
tina and measles. In the former, he asserts, the albuginea exhibits a 
uniform red tinge, with little or no suffusion of tears; in the latter 
malady, the redness is not general or uniform, the injected capillaries 
of the conjunctiva leaving intermediate spaces of a natural or white 
colour. (Ziegler's Beobachtungen, p. 24.) 

The countenance in common synochus, or general inflammatory 
fever, usually exhibits a very different aspect from that which occurs 
in fevers depending on acute local inflammation seated in the thorax 
or abdomen. In the former, the face is more or less tumid and flushed, 
the conjunctiva of the eyes is injected or red, and " the nostrils are 
rapidly and conspicuously dilated and contracted by the hurried re- 
spiration." In acute symptomatic fever, on the contrary, the counte- 
nance is generally somewhat pale and contracted, and there is no 
hurried movement of the nostrils, nor redness of the eyes, if the in- 

* Recherches sur PInflammation de I'Arachnoid, Cerebrale et Spinale. Par 
Duchatelet et L. Martinet, Paris, 1821. 



GENERAL DIAGNOSIS. 91 

flammation be not seated in the head. In the acute bronchitis of 
infants tlie face is invariably remarkably pale: whereas, in infantile 
remittent and common synochus fever, from cold, it is almost con- 
stantly suffused with a flush. It must be observed, however, that in 
the adv^anced stage of pneumonic inflammations, whether in infants 
or adults, when the minute bronchial ra,mifications have become loaded 
with mucus, or serous effusion has taken place into the pulmonary 
tissue, the countenance acquires a more or less distinct livid hue — a 
phenomenon always indicative of great danger. On the other hand, 
the countenance, which is flushed in the early stage of synochal or 
remitting fever, becomes pale and somewhat shrunk, towards the 
termination of the disease. 

I pass on in the next place, to notice those diagnostic circumstances 
which relate to the attitude and motions of the patient. The mor- 
bid variations of attitude are best understood, by contrasting them 
with the healthy postures of the body during sleep. " It may be 
presumed, that, both in health and in disease, that posture is assumed 
which affords the most repose to the system in general, and most relief 
in the performance of its various functions. In healthy and undis- 
turbed sleep the usual posture is that of one side ; the head and shoul- 
ders are generally somewhat raised, and, together with the thorax, 
bent gently forwards; the thighs and legs are in a state of easy flexion. 
The position is apt to be changed from time to time, the person lying 
on one or the other side alternately. The posture of the body during 
sleep, here described, is such as affords the most ease and repose to 
the different viscera, and most facility and disincumbrance in the per- 
*formance of their functions, and such as allows of the greatest mus- 
cular relaxation compatible with these more essential points." 

The supine position (decubitus dorsalis) when attended with 
twitching of the tendons, or tremor of the extremities, always indi- 
cates great muscular debility. When in the progress of a continued 
fever, we find the patient to assume this posture with the inferior ex- 
tremities extended, we may presume from this symptom alone, that 
the disease is assuming a sinking or typhus character. This is still 
more decidedly the case, when in connection with this position the 
patient gradually slides down towards tlie foot of the bed. It requires 
much less muscular exertion to maintain the supine posture than any 
other that can be assumed. In a very debilitated condition of the 
system, there is not enough of muscular power to preserve the body 
in the lateral posture. If the patient be placed on one side, he soon 
turns on his back, and is utterly unable by his own exertions to re- 
sume the lateral position. Celsus observes, that when a person affected 
with fever lies on one side, with the legs slightly retracted, he may 
be regarded as not in a very dangerous condition. 

In relation to the degree of muscular energy manifested by patients, 
there exists a marked difference between idiopathic and symptomatic 
fevers. In common acute fevers of an idiopathic character, the pa- 
tient soon feels very weak, and cannot support himself in the erect 
posture, without great and exhausting efforts, and a feeling of faint- 
ness. This is rarely the case in symptomatic fever. In fevers of 



92 GENERAL DIAGNOSIS. 

this kind, the sense of prostratien is seldom great, nor do we observe 
the muscular tremor, vertigo and faintness on assummg the erect 
position. . 

In the diseases of the chest, the position assumed by the patient is 
often highly characteristic. In hydrolhorax, the patient usually lies 
with the head and shoulders considerably elevated, by additional pil- 
lows. When out of bed, he is often observed to sit up, with the arms 
placed along the side, and the hands fixed and pressing forcibly on 
the chair or sofa on which he sits ; in other cases he leans a little back- 
wards, still supported by the arms and hands, which are placed be- 
hind his back. " This kind of posture is often constant, or immedi- 
ately resumed, if any accident occasions it to be changed ; it gives rise 
to an elevation of the shoulders, from which the body is supported, 
or as it were suspended," The attitude of course varies with the de- 
gree and progress of the hydropic effusion in the chest. In order that 
the patient may continue to enjoy some rest while lying down, the 
head and shoulders must be more and more raised, until, at last, he 
is, sometimes, incapable of remaining in bed, and is obliged to sit up 
"with the legs hanging down," When hydrothorax is associated 
with organic disease of the heart, or of the lungs, the necessity of 
remaining in the erect posture is, in general, particularly urgent. 
These circumstances admit of a ready explanation. The eflused 
fluid in the chest, produces distress and difficulty of breathing in pro- 
portion as it presses upon and impedes the free action of the lungs. 
In a recumbent position, with the head and shoulders low, it is obvious 
that the fluid must envelop and encumber a much larger portion of 
the lungs than when the patient is sitting up, or lying with the shoul- 
ders elevated; for in this posture the fluid sinks down to the bottom 
of the thorax and leaves a considerable part of the lungs free from 
its embarrassing pressure. Hydropic accumulation in the chest may- 
be distinguished from mere organic disease of the heart or of the 
lungs, attended with symptoms resembling those of hydrothorax, by 
making Arm pressure on the abdomen and attending to the effects. If 
there is thoracic effusion, the patient will experience general agitation, 
cough, and a sense of suffocation when pressure is thus made on the 
abdomen. This arises from the abdominal viscera being pressed up 
against the diaphragm, by which the fluid in the chest is raised, so as 
to embarrass the lungs and cause the phenomena just mentioned. In 
organic affections of the heart, without thoracic effusion, no effects 
result from abdominal pressure. In affections of this kind, as well 
as in hydrothorax, the patient is unable to remain easy in a recum- 
bent posture with the head low, more especially in very severe cases* 
But in addition to this circumstance, the effects which arise from 
corporeal exertions in organic affections of the heart, are much more 
violent and distressing than in hydrothorax. Almost every muscular 
effort or unusual exercise produces, to an extreme degree, dyspnoea, 
anxiety, and agitation. Ascending stairs, or a hill, seldom fails to 
bring on a paroxysm of the most alarming palpitation, and suffoca- 
tive breathing. Although similar effects result from the operation of 
these causes in hydrothorax, yet, they are much less violent and 



GENERAL DIAGNOSIS. 93 

alarming tlian in cardiac diseases. When in hydrothorax, ihe drop- 
sical effusion exists only on one side of the chest, the patient invaria- 
bly lies on the affected side. 

Injldmmalion in the abdomen, luith acnte pain, is in general 
attended with a characteristic position of the body, and which dis- 
tinguishes affections of this kind, very pointedly, from .spasmodic 
pains of the stomach and bowels. In acute abdominal inflammation 
the patient assumes a certain position and carefully avoids active 
muscular exertion and change of posture. In spasmodic pains in 
the abdomen, or co/ic, on the contrary, the patient usually "writhes 
to and fro," and constantly changes his posture. In abdominal 
inflammation the patient lies on the back, with the knees drawn up, 
and the head and shoulders raised by additional pillows, so as to 
relax the abdominal muscles and obviate as much as possible, pres- 
sure on the inflamed viscus. Great care, moreover, is taken to pre- 
vent any pressure from the hands or bedclothes on the abdomen, 
and all the necessary motions of the body are performed with pecu- 
liar caution and slowness. In spasmodic or colic pains, so far from 
avoiding pressure on the abdomen, the patient often lies on the belly, 
or presses forcibly on the bowels with his hands. After the paroxysm 
of pain in colic is over, the patient resumes an easy position ; but in 
the absence of an aggravation of inflammatory pain, the same cau- 
tious posture and manner are still retained as before. (Hall.) 

When the inflammation is seated in one of the kidneys, the patient 
when in bed, inclines his body a little forwards and towards the side 
affected. By this position the muscles of the loins on the aflected 
side will be somewhat relaxed and the pressure on the inflamed kid- 
ney diminished. When, in the advanced stages of typhous or typhoid 
fevers, attended with delirium, the patient is observed to keep his 
inferior extremities constantly drawn up, while recumbent on the 
back, retention of the urine may be suspected. I have known 
patients affected with typhoid fever, and in such a condition as not 
to be able to give an account of their sensations, in whom protracted 
retention of the urine was detected solely by noticing this retraction 
of the legs, or constant raised position of the knees. 

In most instances of inflammation of the liver, the patient cannot 
lie on the left side without great aggravation of his sufferings. This 
symptom is, indeed, not always present in hepatitis, and when taken 
by itself, cannot be regarded as of any particular diagnostic import- 
ance. When it occurs, however, in connection with other symptoms 
indicative of hepatic inflammation, it may be considered as no incon- 
siderable evidence of the existence of this affection. If in a case of 
hepatitis, the patient is observed to lie easiest on the left side, we may 
infer that the inflammation is principally seated on the concave sur- 
face of the liver. 

Next in order are the diagnostic signs manifested by the tongue, 
wums, cavity of the mouth, fauces and teeth. In examining the 
tongue, particular attention should be paid to its colour, form, sur- 
face, and mode of protrusion. In the simple forms of fever, unat- 
tended with inflammatory irritation of the mucous membrane of the 



94 GENERAL DIAGNOSIS. 

Stomach, the tongue is sHghtly coated with a white far. This state 
of the tongue is rarely attended with dryness, and does '^^t, m gene- 
ral, indicate a very great degree of gastric derangement. vV_hen iii 
the progress of a disease the-tongue changes from a white and some- 
what loaded state, to a clean and deep red appearance, we may infer 
with confidence, that inflammation has supervened in the mucous 
membrane of the stomach. A clean and red appearance of the 
tongue, attended either with a rough or a smooth surface, is always 
to be regarded as conclusive evidence of an inflamed or highly irri- 
tated condition of the mucous membrane of the alimentary canal. In 
dysentery, we generally find the point and margin of the tongue of 
a deep red appearance, whilst the centre is loaded with a streak of 
brown and dry fur. This is particularly apt to be the case in the 
chronic form of the disease. In chronic gastritis and enteritis, the 
tongue almost invariably exhibits a dark red appearance. In some 
instances, this redness is attended with a rough or granulated sur- 
face, and in others it presents a smooth or glossy appearance ; some- 
times the whole surface of the tongue exhibits this red and rough or 
glossy appearance. This is generally the case when the inflamma- 
tion is seated in the stomach. In many instances, however, these 
appearances are confined to the tip and margins of the tongue, more 
especially when the inflammatory irritation is located in the mucous 
membrane of the colon. 

In fevers depending on acute inflammation, not seated in the mu- 
cous membrane of the alimentary canal, the tongue seldom exhibits 
any prominent deviations from its natural state. Thus in fevers from 
wounds, from regular gout, and from external phlegmonous inflam- 
mation, the tongue generally varies from its healthy condition only 
by being covered with a thick white fur, and by unnatural dryness. 
— (Hall.) In the commencement of typhus fever, the tongue is 
coated with a white fur, as in common synochus fever ; but the white 
tongue of typhus differs from that of simple acute fever, in being 
covered with a thick layer of transparent, tenacious slime, which in 
the progress of the disease becomes dry, brown, and finally nearly 
black. The appearance of the tongue affords a good distinguishing 
sign between tubercular phthisis pulmonalis, and hectic fever with 
cough from hepatic or gastric disease. In genuine pulmonary con- 
sumption the tongne very generally retains nearly its natural appear- 
ance ; whereas in affections of the stomach and liver simulating 
phthisis pulmonalis, the tongue is always more or less coated with a 
brown fur, accompanied usually with a depraved taste. 

In the early stage of chlorosis the tongue presents a pale and 
tumid appearance, with enlarged and prominent papilla. As the 
disease advances the tongue becomes more and more pallid, clean 
and smooth, -and finally acquires a peculiar flabby and semi-trans- 
parent appearance. The gums and prolabia are very pale and 
exsanguious, and generally somewhat swollen. Hall gives the fol- 
lowing description of the morbid appearances of the tongue in dys- 
pepsia. "In acute dyspepsia, the tongue is in general %aded, the 
mouth clammy, the taste bitter or nauseous, the breath fetid whilst 



GENERAL DIAGNOSIS. 95 

the surface of the face is generally oily. In some severe cases the 
coat on the tongue is very thick, and, eventually peals off, leaving 
its surface smooth, red and tender, attended with an oedematous 
•appearance of its substance. In very protracted and severe cases of 
dyspepsia the tongue is apt to become clean, with universal enlarge- 
ment of the papillas over the surface as in the beginning of chlorosis; 
or its surface is formed into lobules resembling in form those of the 
base of the cerebellum. In cases attended with chronic inflamma- 
tion of the mucous membrane of the stomach, the surface of the 
tongue becomes red, smooth and glazed." The appearance of the 
tongue in chlorosis does not differ materially from that which it 
presents in chronic dyspepsia, except that in the former disease it is 
pale instead of red, and indicates, in addition to gastric derangement, 
a defect in the process of sanguification. — (Hall.) 

A contracted and pointed tongue, is a very common attendant on 
inflammatory affections of the brain and its meninges. This state of 
the tongue is often to be observed in very severe cases of typhus; and 
when it does occur we almost invariably find it associated with other 
indications of cerebral inflammation — such as red and prominent 
eyes, constant delirium, flushed cheeks, &c. In fevers attended with 
stupor or general torpor, depending on congestion, the tongue in- 
stead of being contrated and pointed presents a dilated and flabby 
appearance. This relaxed and dilated state of the tongue is seldom 
accompanied by delirium ; but instead of this, there is usually a gene- 
ral diminution of sensibility and irritability, as well as of muscular 
power and the temperature of the surface. Dr. Miner mentions this 
appearance of the tongue as one of the most constant symptoms of 
typhus syncopalis. 

A tongue covered with yellow, or yellowish brown fur, attended 
with a bitter taste, indicates prominent derangement of the biliary 
organs. A tremulous tongue is, in general, one of the first symptoms 
of the passage of the synochus fever into a typhous or low state. 

In the early stage oi scarlatina, a number of florid papillas protrude 
through the white coat on the surface of the tongue ; and Bateman 
states, that this appearance will always enable .us to distinguish it 
from measles. In chronic hepatitis, the gums have a peculiar firm, 
smooth, or glossy appearance, whereas in chronic dyspepsia, they 
usually present a soft or spongy condition. 

The next class of symptoms to be considered are those manifested 
by the nervous system. The most common, and generally the ear- 
liest symptom of deranged function of the brain, is disturbed sleep. 
In the diseases of children an unusual drowsiness, especially when 
attended with a disordered state of the alimentary canal and febrile 
irritation, is often one of the first symptoms to awaken alarm and 
suspicion of probable disease within the head. Under whatever cir- 
cumstances profound morbid sleep or coma may occur, it always de- 
notes cerebral oppression from congestion or effusion, or some other 
cause capable of compressing this organ. When, therefore, in the 
course of diseases attended with symptoms of cerebral irritation or 
inflammation, somnolency supervenes, we may conclude that great 



96 GENERAL DIAGNOSIS. 

congestion, or effusion, or disorganization of the cerebral structure, 

has taken place. . , „ct;rir, 

Wakefulness is indicative of great cerebral irritation or exnausiion. 
It is particularly apt to occur from sympathetic excitement ot the 
brain, depending on intestinal irritation, and exhaustion trom loss 
of blood. When morbid wakefulness depends on these causes, it is 
almost invariably attended with great restlessness or jactitation, a dis- 
tressing feeling of anxiety in the region of the heart, and a pale and 
contracted countenance. Sudden starting during sleep is generally 
connected with intestinal irritation from indigestion or worms. (Hall.) 
Children whose bowels are loaded with sordes or worms are parti- 
cularly apt to start in sleep, "and this symptom is one of the most 
certain diagnostic signs of such a condition of the alimentary canal." 
Similar huried wakenings occur in organic affections of the heart, and 
in hydropericardium, and frequently, also, in hydrothorax ; but in 
these complaints, the starts from sleep are almost always attended 
with a distressing sense of suffocation, or impending dissolution, great 
agitation and alarm. 

Acuteness of hearing and sight occur in the incipient stage of.cere- 
bral inflammation; but they are equally, and often more strikingly 
presented in sympathetic irritation of the brain from intestinal irrita- 
tion, accompanied with exhaustion. (Hall.) As a general observa- 
tion, however, it may be said that when the senses of sight and hearing 
are morbidly acute, or when there is intolerance of light and sound, 
the brain is in a state of irritation, whether sympathetic or idiopathic. 
Obtuseness of hearing is a common symptom in the advanced stages 
of typhoid fevers, and indicates a considerable degree of sanguineous 
engorgement, but not inflammation of the brain. 

Strabismus, and seeing objects double, always denote very consi- 
derable. cerebral disturbance. These symptoms arise from sanguine- 
ous or serous effusion into, or upon the surface of the brain, and from 
disorganization of a portion of the structure. Torpor or defect in the 
sense of touch, if general or confined to one side of the body, indicates 
an oppressed state of the brain, and may be both the precursor or 
consequence of apoplexy. When torpor of feeling is confined to one 
extremity, or only to a part of an extremity, we may infer that the 
nervous communication between the affected part and the sensorium 
commune has been partially interrupted, by compresssion of the prin- 
cipal nerve leading to the part, or that the nervous extremities of the 
part have become diseased and incapable of transmitting the nervous 
power. 

Morbid sensations are among the most common phenomena of 
diseases. In many affections, indeed, there are peculiar and charac- 
teristic modifications of sensibility, which it is of importance to notice 
in a diagnostic point of view. In strumous disease of the mesentery, 
an unusual sensibility to cold constitutes a peculiar and very early 
symptom. " In this disease, the patient is greatly sensible to cold and 
to the least draught of air, and in cold weather especially, constantly 
draws near or hangs over the fire, until the hands and legs assume a 
brown colour from the influence of the heat." 



GENERAL DIAGNOSIS. 97 

Pain may depend on inflammation, on spasm, or on nervous irri- 
tation. Each of these kinds of pain has a peculiar character by 
which it may in general be readily distinguished. The pain of 
inflammation is attended with great tenderness or soreness of the 
afl'ected part — is increased by pressure — generally continuous, and 
always attended with more or less of febrile irritation. Spasmodic 
pain, on the contrary, is intermitting — is neither tlirobbing nor burn- 
ing, like that of inflammation, nor is it attended with redness, swell- 
ing, augmented heat, or febrile excitement. Pressure, which always 
increases the pain of inflammation, generally mitigates spasmodic 
pains. Neuralgic pain differs from inflammatory and spasmodic 
pain, by occurring in transient and extremely violent paroxysms. It 
darts with the rapidity of lightning along the ramifications of the 
affected nerve. It is not attended by swelling or increased heat, 
unless some degree of inflammation be associated with it ; and the 
slightest agitation or touch is apt to renew its excruciating par- 
oxysms. 

It is a fact demonstrated by daily observation, that the character 
of inflammatory pain is peculiarly modified by the nature of the 
structure in which the inflammation resides. This circumstance 
necessarily arises from the physiological fact, that each structure of 
the animal system is endowed with a peculiar modification of the 
vital properties. From this variety in the general character of in- 
flammatory pain, according to the structure in which it resides, we 
frequently obtain important diagnostic indications. In the mucous 
membranes, inflammation is attended with a burning or stinging 
pain, and is seldom very violent : in the serous membranes the pain 
is lancinating, and generally extremely acute ; in the fibrous tissues, 
it is dull, aching and gnawing; in the nerves, rapid, darting, remit- 
ting and excruciatingly severe ; and in the parenchymatous and cel- 
lular structures, it is dull, throbbing and heavy. Thus the pain 
experienced from inflammation of the pleura, is acute, piercing, and 
generally extremely severe ; whilst that from inflammation of the 
substance of the lungs is dull, pressing, and generally inconsiderable 
in violence. The pain attending inflammation of the mucous mem- 
brane of the stomach is of a burning, gnawing, or stinging character ; 
that of the liver is acute, throbbing, and generally accompanied with 
a sense of fullness and tension in the right hypochondri\im and epi- 
gastrium. The character of the pain may, moreover, assist us in 
determining in what portion of this organ the inflammation is prin- 
cipally seated. When the substance of the liver is the principal or 
exclusive seat of the inflammation, the pain is seldom very acute or 
violent — being obtuse, heavy, and heating. When the convex sur- 
face of this organ is aflfected, the pain is usually extremely severe, 
darts upwards towards the left or right shoulder, and is always much 
increased by external pressure, deep inspiration, cough, and motion. 
In cases where the concave surface is the seat of the inflammation, 
the pain is, in general, dull, accompanied with much anxiety in 
the epigastrium, nausea, and often vomiting. Cases of this kind 
frequently resemble gastritis ; but may be distinguished from this 

VOL. I. — 7 



98 GENERAL DIAGNOSIS. 

affection by the pain, distress and vomiting not being increased by 
taking warm liquids into tlie stomach. . 

In many instances, the painfnl sensation is referred to a dillerent 
and often remote part from that in which the primary nTitation or 
affection is seated. Irritation in the neck of the bladder frequently 
gives rise to pain in the glans penis; intlammation of the liver often 
causes pain in the left, and sometimes right shoulder; and severe 
and protracted pain in the knee and legs, is generally among the 
first painful sensations attending hip disease. In many cases, in- 
deed, pain in the knee is felt for a considerable time before any un- 
pleasant sensations are experienced or complained of in the iiip ; and 
I have not unfrequently known various applications made to the 
knees of children for the relief of pain in that part, which was subse- 
quently found to be merely symptomatic of scrofulous disease of the 
hip. Inattention to these and similar facts has often led to very use- 
less and painful applications, and placed the physician under the 
mortifying, and, indeed, justifiable imputation of ignorance or culpa- 
ble carelessness. 

The next class of symptoms to be considered, are those manifested 
by the morbid conditions of the alimentary canal. From the nature 
and appearance of the alvine evacuations, we may often derive im- 
portant diagnostic information. The functional derangements of the 
liver are, in general, readily distinguished by the character of these 
evacuations. Ash, or clay-coloured faeces indicate either deficient 
secretion of bile, or obstruction to its regular flow into the intestines. 
This condition of the biliary organs is almost always attended with 
mcreased irritability of the stomach. When the alvine discharges 
are liquid, and of a bright green colour, as is frequently the case in 
infants, the existence of much acid in the bowels may be confidently 
inferred. Bile, as it comes from the liver, never possesses such a 
colour. It is only by being mixed with acid in the intestines, that 
it acquires this appearance. However dark and vitiated the bile may 
be before it is discharged into the bowels, it will always communi- 
cate a yellow colour to water. It becomes green in the intestines 
by the action of the acid it meets there. According to the observa- 
tions of Dr. Cheyne, the appearances of the stools afford a good 
diagnostic sign between infantile remittent fever and hydrocephalus. 
In the former disease, the alvine discharges are, generally, dark 
brown or mud-like, and extremely fetid. In hydrocephalus, the 
stools are usually gelatinous, dark green, sometimes black, like tar, 
and of a peculiar sickly smell. Watery and reddish stools, contain- 
ing small flakes of mucus, resembling the washings of flesh, always 
indicate a high degree of inflammatory irritation of the mucous 
membrane of the small intestines. 

The diagnosis of diseases is also much aided by an attention to 
the morbid conditions of the respiratory organs. In general, the 
greater the velocity and momentum of the blood, the more rapid is 
the respiration. In acute diseases, attended with a frequent and full 
pulse, breathing is always accelerated. In affections of the head, 
attended with sanguineous congestion in the brain, respiration is 



GENERAL DIAGNOSIS. 99 

generally more or less irregular, unequal and suspicious. When the 
congestion, and consequent cerebral compression, is so great as to 
produce partial insensibility, the breathing becomes slow, irregular 
and stertorous. Whatever obstructs the functions of the brain, or 
interrupts the nervous communication between it and the respiratory 
apparatus, impedes or destroys the function of respiration: and the 
slowness and irregularity of the respiratory acts will be in proportion 
to the degree in which the functions of the brain are oppressed. 

In pneumonia, breathing is sometimes performed by the action of 
the diaphragm alone, without any perceptible elevation and depres- 
sion of the ribs of the affected side. In abdominal inflammation, 
with acute pain, on the contrary, respiration is performed almost 
exckisively by the action of intercostal muscles, the alternate rising 
and falling of the abdomen, so conspicuous in thoracic inflammation, 
being almost entirely absent. " This peculiarity of breathing," says 
Dr. Hall, " may be distinctly observed by looking on the chest and 
drawing the bed-clothes tight over the abdomen : the respiration has 
sometimes the appearance of heaving of the chest ; every movement 
of the diaphragm is cautiously avoided on account of the motion 
which its action communicates to the abdominal viscera. The dia- 
phragm and abdomen begin to move, as the pain diminishes, whether 
from mitigation of the disease, from sinking, or from gangrene." 

In inflammation of the substance of the lungs, or of the mucous 
membrane of the ultimate bronchial tubes, respiration is performed 
with great diflicuUy, and in violent cases with distressing anxiety 
and labour. '• The shoulders are elevated, and the lower part of the 
sternum is drawn back, during each act of inspiration, whilst the 
abdomen is at the same time suddenly protruded, and the upper part 
of the chest raised." In the diseases of children, the manner in 
which respiration is performed often throws important light on the 
character of the disease. When, with more or less cough, the inspi- 
rations are short and catching, more especially when the countenance, 
at each inspiration, exhibits an expression of pain or suffering, the 
existence of pectoral inflammation may be confidently inferred. If 
the countenance is pale, and the breathing wheezing and laborious, 
the inflammation is probably seated in the mucous membrane of the 
bronchia. 

Laborious and anxious breathing on muscular exertion or strong 
mental excitement, particularly from walking up hill, or ascending 
stairs, is strongly indicative of organic disease of the heart. The 
dyspnoea of hydrothorax differs from that of organic cardiac disease, 
in being more liable to recur in violent paroxysms from the causes 
just mentioned in the latter than in the former affection. In hydro- 
thorax, too, the dyspnoea, thus excited, comes on gradually, whilst 
in organic disease of the heart the paroxysm of suffocative breathing 
recurs with sudden violence. Asthma is attended with a peculiar 
mode of dyspnoea. The act of inspiration consists of a quick and 
imperfect dilatation of the thorax, but expiration is much more pro- 
tracted, laboured and wheezing. "When the disease is violent, 
every muscle subservient to this function is brought into strong exer- 



100 GENERAL DIAGNOSIS. 

tion, with the exception of the intercostals, which, aUhough excited 
to strong efforts, are incapable of that degree of action wliicli is ne- 
cessary for the due expansion of the chest. What, however, par- 
ticularly characterizes the dyspnoea of asthma, is the wheezing during 
expiration." 

When the breathing is hurried, panting, sighing, and the lungs are 
but partially filled during inspiration, there is probably much debility 
accompanied by or depending on nervous intestinal irritation. This 
state of the system and of the respiratory organs is generally attended 
with great restlessness, jactitation, and inability to sleep. 

Having described some of the more remarkable diagnostic phe- 
nomena, in relation to respiration, it remains for me to consider the 
diagnostic indications derived from the character and attending cir- 
cumstances of coughing. 

With regard to the phenomena of cough, therefore, we may notice 
the following general diagnostic circumstances : — Patients affected 
with inflammation of the pleura, lungs, or peritoneum, always repress 
the cough as much as possible, in order to obviate the great increase 
of pain which free coughing invariably produces in these affections. 
When, therefore, the patient is observed to make great efforts to 
stifle or suppress the acts of coughing, the existence of local inflam- 
mation may be confidently inferred. The seat of the inflammation 
Avill be pointed out by the other accompanying symptoms. The 
cough attending acute inflammation of the mucous membrane of the 
bronchia has a much duller sound, and is attended with much more 
mucous rattling in the chest than that which results from acute 
inflammation of the pleura. This remark applies particularly to the 
early period of these affections ; for in the advanced stage of the 
latter malady, the cough is generally as dull and rattling as in bron- 
chitis. Cough depending on gastric or intestinal irritation, is gene- 
rally attended with a peculiar hollow sound: this kind of cough is 
frequently met with in children labouring under verminous irritation. 
The character of the cough will, in general, afford considerable aid 
in distinguishing phthisis laryngea from phthisis pulmonalis ; or that 
form of consumption which arises from ulceration in the larynx, from 
true pulmonary consumption. In the former the cough comes on 
in violent and spasmodic paroxysms, particularly in the morning on 
rising from bed; whilst in the latter form of the disease, the cough is 
usually much less sudden and violent in its attacks, and is, besides, 
destitute of the spasmodic or convulsive character of the former, hi 
the laryngeal variety of the disease, the cough has a deep hollow 
sound, not unlike that which is produced by verminous irritation of 
the bowels, whereas, in pulmonary phthisis, it always has a "flat- 
tened and lacerating sound." In the former of these maladies, violent 
fits of coughing are excited by the patients passing from a warm 
into a cold air, by inhaling smoke or the dust raised by sweeping, or 
any irritating fumes, and the same effect is frequently produced by 
swallowing food. In pulmonary phthisis, coughing is very rarely 
excited by these causes, and when they do produce this effect the 
cough is usually slight and of very short duration. ' 



GENERAL DIAGNOSIS. 101 

The character and appearance of the matter expectorated afford 
important diagnostic indications. In peripneumonia, the tenacity 
of the matter expectorated is so great, that we may reverse the ves- 
sel which contains it, and retain it in this position for some time, 
without detaching it from its sides. Laennec regards this kind of 
sputa, as pathognomic of this affection, "since it is the only symptom 
which is found exchisively in this form of pulmonic inflammation." 
These sputa are somewhat diaphanous and of slightly yellow or 
greenish colour. In acute bronchitis the expectoration is much less 
tenacious in its consistence, and is generally quite transparent, resem- 
bling the white of eggs. When tlie fluid expectorated has a dark 
appearance, like dissolved blood, and possesses a very fetid smell, 
we may infer that some portion of the diseased lung is in a gan- 
grenous condition. In chronic bronchitis, particularly in those cases 
which result from pertussis, the matter expectorated often presents a 
white cream-like appearance, bearing considerable resemblance to 
the whitish friable matter which is sometimes brought up in small 
quantities in the latter stage of tubercular phthisis. This white 
matter, in the latter disease, consists of the softened substance com- 
posing the tubercles. Mucous membranes, under a high degree of 
irritation, often secrete a fluid which bears a strong resemblance to 
genuine pus; but which, in its composition and properties, is never- 
theless, strictly a mucus. Various tests have been recommended for 
distinguishing puruloid secretions of this character from genuine 
pus, and a correct decision on this point is of much importance in 
forming a satisfactory diagnosis; for when the matter expectorated 
is found to be pus, there can be no doubt, that the structure from 
which it proceeds is in a state of active ii.flammation or ulceration. 
If, on the contrary, it be found to possess the character of mucus, 
we may infer, that neither an active state of inflammation nor ulcer- 
ation exists in the diseased organ, but only a high degree of irrita- 
tion, or sub-inflammatory excitement. The specific gravity of pus 
is considerably greater than that of mucus — the former sinks in 
water, the latter floats on the surface. This is the usual test, but 
cannot always be relied on; for although we may safely pronounce 
the matter expectorated to be pus, when it sinks quickly to the bot- 
tom of the vessel, yet we cannot with entire assurance, infer that it 
is mucus when it remains floating on or near the top of the water; 
for a considerable portion of pus is often so intimately mixed with 
bronchial mucus, as to give it a nearly uniform appearance, and 
cause the sputa to swim on the surface. The following tests have 
been proposed, and I think, entitled to confidence. — The muriate of 
ammonia coagulates pus; but on mucus no such effect is produced 
by it. Heat coagulates mucus, but not pus. Water added to the 
solutions of pus in sulphuric acid, and in a solution of caustic potash 
separately, produces, in each, a copious precipitate. Mucus treated 
in the same way, does not exhibit the same effect Dr. Young men- 
tions the following test : A small portion of pus put betweei] two 
glasses, will, when held near the eye, and looked through at a dis- 
tant candle, exhibit an iridescent spectrum, of which the candle is 
the centre. Mucus does not present this phenomenon. 



102 GENERAL DIAGNOSIS. 

The morbid conditions of the external surface of the body should 
always be carefully observed. In examining diseases, particular 
attention should be paid to the temperature, the colour, the state of 
dryness or moisture, the fullness or constriction, and the roughness 
or smoothness of the skin. The existence of oedema, or of emacia- 
tion, moreover, is an important diagnostic circumstance. A yellow- 
ish or icteric hue of the skin, and especially of the tunica albuginea, 
is a well-known indication of derangement of the biliary organs. 
In the various forms of disease produced by marsh miasmata, this 
symptom is rarely absent. This appearance of the skin, says Mr. 
Hall, nmst not be confounded with the sallow hue which occurs in 
chlorosis, cancer, and some other organic affections. " Sallowness 
is not necessarily accompanied by a yellow hue of the albuginea; 
but the icteric appearance of the skin is always associated with a 
similar tinge of the eyes. When, therefore, the albuginea is free 
from this yellowish hue, we may infer that the biliary organs are 
not particularly disordered, however sallow the general surface may 
be. When a decided icteric or jaundiced hue of the skin, is asso- 
ciated with constant and obstinate torpor of the cutaneous exhalents, 
or dryness of the surface, we may infer that the biliary derangement, 
upon which these phenomena depend, consists of chronic inflamma- 
tion and induration of the liver: and this diagnosis may be regarded 
as still more certain, if, at the same time, the gums have a peculiar 
and unnatural firmness. A purple or bluish colour of the skin, when 
not the immediate consequence of cold, indicates deficient decarbon- 
izationof blood in the lungs. This appearance occurs, in a striking 
manner, in the Asiatic cholera. When this livid hue is confined to 
some particular part of the body, it denotes great venous congestion 
in the part. Thus a livid colour of the face indicates great en^gorge- 
ment of the blood-vessels of the head, and is almost universally con- 
nected with, or rather dependent on, obstructed circulation through the 
lungs, and attended with an imperfect performance of the respiratory 
functions. 

A pale semi-transparent appearance of the surface, particularly of 
the prolabia and face, occurs after profuse hemorrhage, or from 
whatever greatly exhausts the system or produces the process of 
sanguification. This appearance of the skin is alwaj^s accompanied 
by great languor and debility, and depends, generally, on a morbid 
excess of the serous portion of the blood. This state of the system is 
almost invariably attended with more or less of anasarcous eflusion. 
A pale and cachectic appearance of the face, attended with a leaden 
hue of the prolabia and a pvffy swelling under the eyes, is fre- 
quently noticed in organic affections of the heart. A cold state of 
the surface of the body, attended with a sensation of heat in the in- 
ternal parts, indicates great sanguineous congestions of the viscera. 
The heat is sometimes very unequally distril)uted throuf^hout the 
various parts of the body, and it may be laid down as a general rule, 
that in whatever part the heat is preternaturally elevated, there is an 
unusual determination of blood to that part. Thus in hydrocephalus 
the head is almost always considerably warmer than any other part 
of the body; and in dysentery and peritonitis the abdomen is preter- 



GENERAL DIAGNOSIS. 103 

naturally hot to the touch, whilst the extremities in the latter stage 
of the disease are unusually cool (Hall). lu organic affections of the 
heart, the hands, nose and cheeks are very apt to become preterna- 
tural ly cold, whilst the heat within the rectum and under the tongue 
is generally considerably higher than natural (Fare). A pungent, 
stinging heat of the surface, or the calor mordax, as it is technically 
called, indicates a high grade of malignity or a tendency to putres- 
cency in fevers. This pungent heat difiers very distinctly from the 
burning heat which occurs in syuochial or inflanmiatory fever. By 
laying the hand on the skin of a patient labouring under inflamma- 
tory fever, the sensation of heat is at iirst very great, but on suffering 
the hand to remain for a short time, the sensation of heat gradually 
diminishes, until it seems to the touch but little, if in any degree, 
above the natural temperature of the body. In typhus gravior, on 
the contrary, the heat [calor mordax) becomes more and more pun- 
gent and severe, and the biting or acrid sensation of heat remains in 
the hand, even after it is removed from the patient's body. 

The appearances and character of the urine also often afford valu- 
able diagnostic indications. In inflammatory affections it is generally 
very red and small in quantity ; in nervous diseases, more especialh/ 
in hysterical affections, this secretion is usually copious and limpid, or 
but slightly coloured. In diseases of the biliary organs, the urine is 
almost invariably conspicuously tinged with bile. To distinguish 
urine coloured with bilious matter from the highly-coloured urine of 
inflammatory fevers, a small strip of white linen or paper should be 
immersed in it. If the urine contains bile, the linen or paper will 
receive a very distinct yellow stain, which will remain when dried. 
If it be free from bilious matter no such tinge will be communicated. 
Much has of late years been said concerning the connection between 
a serous or coagulable condition of the urine (in hydropic affections), 
and a phlogistic or inflammatory state of the system. Drs. Blackall, 
Wells, and Ayre,have investigated this subject with minute attention. 
It has been satisfactorily ascertained by these and other pathologists, 
that those cases of dropsy which are attended with an obvious phlo- 
gistic diathesis, and especially such as arise from the influence of 
general causes, the urine, with scarcely an exception, contains a large 
quantity of coagulable serum. The quantity of serum mixed with 
the urine may, therefore, be regarded as a pretty correct index of the 
degree of general inflammatory excitement attending the disease. 
Serous urine may be regarded as a sort of pyrexometer in hydropic 
affections, which, though not universally to be relied on, is yet sufii- 
ciently constant to entitle it to the attention of the practitioner. I am 
satisfied, from considerable attention to this subject, that in almost 
every instance where there is coagulable serum in the urine of drop- 
sical patients, the general condition of the system will be found mani- 
festly phlogistic. The mode of testing the urine, for this purpose, is 
to expose a portion of it in a spoon to the heat of a lamp. When, in 
hydropic affections, the urine is high-coloured, and on cooling becomes 
muddy, or deposits a red or reddish sediment, we may infer with 
great probability that the liver is in a state of organic disease (Cruik- 
shank). 



104 



OF THE ACUTE DISEASES OF THE SANGUIFEROUS 

SYSTEM. 



I.— GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS 
INDEPENDENT OF LOCAL INFLAMMATION. 



CHAPTER V. 

OF INTERMITTING FEVER. 

Intermitting fevers occur under the three primary types mentioned 
in a preceding chapter, and occasionally under the various complica- 
lions which these types are liable to assume. According to the type 
which they assume, tiierefore, they are divided into quotidians, ter- 
tians, quartans, quintans, S)'C. 

The fit or paroxysm of an intermitting fever consists of three dis- 
tinct periods, all of which are characterized by a series of peculiar 
phenomena, each succeeding period being the immediate consequence 
of the one which precedes it. 

The symptoms which characterize the forming state of an inter- 
mittent paroxysm, do not differ from those which usually precede the 
development of the other forms of fever. A sense of great lassitude, 
frequently yawning and stretching, a feeling of uncomfortable weari- 
ness of the whole body, and slight aching pains in the loins and 
extremities, constitute the first manifestations of the approach of an 
intermittent fever. 

Cold stage. — After the foregoing symptoms have continued for an 
indefinite time, the patient begins to experience slight and transient 
sensations of cold along the back ; attended often with an irresisti- 
ble disposition to yawn and change the position of the extremities; 
the fingers and feet lose their natural temperature, and feel slightly 
benumbed ; the patient becomes restless, and soon tired of the same 
position ', his ideas pass with unusual rapidity through his mind; he 
is incapable of fixing his attention upon any particular object, and 
generally manifests an unusual irritability of mind, or ill temper, or a 
taciturn moroseness. The sensation of chilliness, with more or less 
rapidity, extends itself from the extremities over the whole body; the 
skm becomes universally pale, contracted, and rough; the pulse loses 
its activity and size, becoming small, contracted, frequent, and firm. 
When the sense of chilliness has passed from the extremities to the 
body, a slight trembling of the muscles begins, generally, at first, in 
the jawsj and extending thence quickly over the whole frame. This 



INTERMITTING FEVER. 105 

trembling is sometimes so severe as to agitate the patient as if he were 
in a paroxysm of convulsions, and sometimes exhausts him so much 
as to leave him scarcely able to move his limbs after their subsidence. 
These tremors are technically called rigors. During the chills the 
sensibility of the surface is benumbed, and the whole body becomes 
diminished in volume, so that rings which were previously tight drop 
from the fingers. The feeling of cold is not confined to the surface, 
but appears in violent cases to penetrate even to the bones, and to 
pervade the whole system, "and is accompanied with an indescrib- 
able sense of universal pain and fatigue."* The breathing also is 
hurried, anxious, and oppressed, and frequently attended with a short 
dry cough, deep sighing, and a sense of weight and tightness in the 
chest. Along with these symptoms there occur usually much de- 
jection and confusion of the mind, and, in some instances, a slight 
degree of delirium. In very debilitated persons a violent fit of rigors 
often induces a complete state of stupor or coma, more especially 
when feebleness of body is attended with general plethora. In many 
instances, frequent and distressing vomiting occurs, particularly about 
the period of its subsidence, and the ejections are generally bilious, 
though occasionally ropy, transparent, and insipid. The thirst is 
always urgent in this stage, and the mouth and fauces are dry and 
clammy. The urine is clear, colourless, without sediment, and often 
copious Generally, the chills are universally diffused over the body; 
but in some cases they occur partially, remaining confined to one or 
more parts of the body ; and instances have been recorded in which a 
single extremity only was affected with the chills. In some cases of 
intermitting fever, the cold stage is attended with but a very slight sen 
sation of chilliness creeping along the back and over the extremities; 
and I have known this stage to commence with violent vomiting, and 
to terminate speedily in stupor and partial insensibility. The duration 
of the cold stage is very various, ranging from a iew minutes to four 
or five hours. Sooner or later, however, the chills begin to abate ; 
transient flushes of heat pass over the face and body ; the chilliness 
now recedes rapidly, and the heat eucxod^ches pari passu, until it has 
obtained an entire ascendency. At this time the nausea and vomiting 
are usually most severe — both of which often continue until the hot 
stage is completely developed. 

The hot stage is characterized by a full and flushed countenance ; 
an intensely hot and dry state of the surface of the body; great thirst 
and dryness of the mouth; great acuteness of the sensorial powers; a 
full, strong, and frequent pulse ; a more free and regular respiration 
than in the preceding stage, though still more oppressed and hurried 
than natural; great pain in the forehead ; pain in the back and extre- 
mities; sometimes slight delirium just before the commencement of the 
succeeding stage ; a scanty and deep-coloured urine without sediment. 
This stage is as various in its duration in different cases, as the pre- 
ceding one. It continues, however, almost always much longer than 
the cold stage. The temperature of the skin is always very consi- 

* MaccuUoch on Intermittent and Remittent Fever, &c. 



106 INTERMITTING FEVER. 

derably augmented. Fordyce observed it as high as 105° of Fahren- 
heit. This stage terminates in the last, or, 

The siveating stage. — When the perspiration begins to appear, an 
obvious abatement of all the febrile symptoms occurs. The sweat 
appears at first about tlie head and breast, and thence gradually ex- 
tends over the whole surface of the body. On the appearance of this 
evacuation, the pulse loses its hardness and fregi(e)7ci/,but still re- 
tains its fullness. The breathing at the same time becomes free and 
natural ; the febrile heat subsides rapidly; and the urine, though still 
very high-coloured, deposits a latcritious or pale red sediment. This 
gradual melioration of the febrile symptoms continues under the free 
flow of the perspiration, until the paroxysm terminates in a state of 
perfect convalescejice or apyrexia. 

The apyrexia, or intermission, though entirely free from febrile 
phenomena, caimot, however, be regarded as a state of health ; for, 
during this interval, the patient usually feels some degree of languor ; 
becomes easily fatigued ; complains often of a want of appetite, and 
an indisposition to bodily or mental exertion. He possesses, more- 
over, an unusual degree of sensibility to the impressions of cold air; 
and his countenance exhibits a pale and sickly aspect. In some, 
though comparatively few instances, the appetite is good, and the 
patient experiences no feelings of indisposition whatever during the 
intermission. The more conspicuous the symptoms of imperfect 
health are during the intermissions, the more difficult, in general, will 
it be to prevent its recurrence ; or, the more readily will it relapse 
after it has been suspended. 

Intermittents of every type are subject to certain prominent modi- 
fications in relation to their general character, which, as they have im- 
portant practical bearings, deserve particular attention. We meet 
with intermittents, for instance, which are attended with unequivocal 
manifestations of an inflammatory character -, others occur in which 
symptoms of great internal venous congestions are equally conspicu- 
ous; a third variety of intermittents will exhibit strong symptoms of 
biliary and gastric irritation ; and a fourth variety will be charac- 
terized by phenomena indicative of a more or less malignant charac- 
ter. According to these circumstances, intermittents may be divided 
into the four following varieties, viz : 1, the inflammatory; 2, the 
congestive ; 3, the gastric ; and 4, the malignant intermittents. 

1. Inflamm.atory intermittents occur most frequently daring 
winter and in spring. Quotidians are more apt to assume this cha- 
racter than tertians; and tertians more apt than quartans (Richter). 
In young, robust, and plethoric subjects, vernal quotidians are espe- 
cially prone to manifest inflammatory symptoms. Intermittents of 
this character generally begin with strong rigors. In the hot stage, 
the temperature of the surface is very intense, and the pulse is pecu- 
liarly strong, hard, and full. The most characteristic marks of inflam- 
matory intermittent occur, however, during the intermission. How- 
ever profuse the perspiration in the last stage, the apyrexia does not 
become complete. The pulse remains quick, somewhat tense and 
accelerated ; the thirst is still considerable, and the skin dry and warmer 



INTERMITTING FEVER. 107 

than natural; the whole system is irritable; the temper is fretful or 
discontented ; slight headache is experienced ; atid transient pains are 
often felt in the extremities and the back. In many instances a short 
and dry cough occurs, with some oppression in the chest, or other 
pectoral aflections. Richter observes, that inflammatory intermittents 
are very rarely attended with symptoms of gastric disturbance from 
vitiated secretions, bile, &c. The intermissions in agues of this kind 
are usually short. (Richter.) 

2. Congestive intermittents occur seldom. They happen gene- 
rally in persons of exhausted and debilitated habits ; and in such as 
are of an irritable and nervous temperament, connected with habitual 
or accidental debility. They are characterized by a very protracted 
cold stage, deep-seated pain in the head, vertigo, fainting, a sense of 
weight or oppression in the breast, coma, a small and weak pulse ; 
the hot stage coming on very slowly, and developing itself very im- 
perfectly, so that instead of hot skin, flushed countenance, and a full 
and vigorous pulse, the system continues to be oppressed, the skin 
scarcely warm, the countenance pale and contracted, the breathing 
confined and anxious, and the pulse frequent, small and tense, with 
an internal sensation of heat. 

3. Gastric intermittents are characterized by prominent symp- 
toms of gastric and intestinal irritation, redundancy of biliary secre- 
tion, and other saburral matters lodged in the alimentary canal. The 
ordinary intermittents of the temperate climates, occurring in autumn, 
are usually of this kind. Intermittents of this modification are at- 
tended with a foul and bitter tongue ; much nausea and bilious vo- 
miting ; great pain in the forehead ; diarrhoea ; an icteric hue of the 
skin and albuginea ; urine loaded with bilious matter ; thirst for acid 
drinks, and sensation of weight or fullness in the right hypochondrium. 
Intermittents of this kind are apt to produce visceral disorders, more 
especially indurations of the spleen and liver, and finally, a cachectic 
condition of the system which is often extremely diflicult to remove. 
(Richter.) 

4. Malignant intermittents are of frequent occurrence in hot 
climates, and are always of the most dangerous character. They are 
characterized by a very copious and fetid perspiration in the third 
stage, together with colliquative haemorrhages from various parts of 
the body, sometimes petechia, and other marks of malignity. They 
run their course with great rapidity, death usually taking place in the 
third paroxysm. (Alibert.) 

Irregular and anomalons intermittents. Intermittents do not, 
however, always pursue the regular course that has just been de- 
scribed. In some instances, anomalies of a remarkable character 
occur, both in relation to the phenomena, and the succession of the 
stages of the disease. I have known a case, in which the first two 
paroxysms occurred in a perfectly regular manner ; but after employ- 
ing arsenic, unsuccessfully, during the second and third intermissions, 
the paroxysms returned without a cold stage, the patient experi- 
encing, instead of it, a peculiar feeling of numbness on the top of the 
head, with great dullness of hearing, for about forty or fifty minutes 



108 INTERMITTING FEVER. 

before the supervention of the hot stage. There are instances on 
record, of the inversion of the natural order of the cold, hot, and 
sweating stages ; several distinct instances of which occurred under 
my observation in the fall of 1828. Cases have been noticed, m 
which the perspiration, in the third stage, was substituted by diar- 
rhoea; and Cleghorn states, that he saw tertians, which terminated 
by ail increased flow of urine, with scarcely any sweat. 

In infants, the paroxysms of intermitting fever are sometimes 
ushered in by convulsions ; but the convulsions are most apt to occur 
at the commencement of the hot stage. Indeed, the cold stage of 
very young children is seldom marked by distinct rigors. A pale 
and shrunken countenance, with an obvious reduction of the tem- 
perature of the surface, yawning, and stretching, usually manifest 
the presence of this stage in infants. 

There are certain affections, not of unfrequent occurrence, which, 
from their strict periodicity, as well as from their apparent origina- 
tion from the same causes that give rise to intermittents, are termed 
masked agues, febres intermiltentes larvatse. Thus, neuralgia, in 
various parts of the body, sciatica, rheumatism of the eye, hsemi- 
crania, toothache, cramp in the stomach, dysentery, cholera, hiccough, 
mania, and acute pains in other parts of the body,* have been known 
to recur in a manner strictly periodical, and to have yielded readily 
to the same remedies which are found to arrest the course of an ague. 
These affections, when thus perfectly periodical, generally manifest 
their alliance to intermitting fever, by being almost always preceded 
by a very shght sensation of chilliness, and by being attended with 
a moist skin and a turbid urine at the termination of the paroxysm. 
(Richter.) 

Intermittents are sometimes complicated with other affections, 
such as dysentery, cholera, jaundice, and visceral inflammations. 
The vernal intermittents are most apt to become complicated with 
inflammatory affections; and those which occur in Autumn are most 
frequently combined with disorders of the alimentary canal and nerv- 
ous system. Paralysis and apoplexy, according to the observations 
of Dr. Macculloch, are by no means uncommon occurrences in inter- 
mitting fever ; and they occur, sometimes, as direct consequences of 
the influence of the miasmata, without any distinct febrile phenomena. 

Many of the affections which supervene in intermittents appear 
to result from the inroads of the fever itself on the constitution : but 
the majority of these maladies, whether occurring as concomitants, 
sequeles, or substitutes of the fever, are, without doubt, direct conse- 
quences of the deleterious influence of the remote cause. Dropsy, 
jaundice, scirrhus, &c., are, probably, usually the result of the general 
febrile disease. Unquestionably, too, aneurismal enlargements of 
the heart and large vascular trunks, must be regarded as the conse- 
quence of the violent congestion of the blood which occurs in the 
internal organs during the cold stage. In the same way, apoplexy 

* Macculloch on Intermiltent and Remittent Fever, &c. See also Joum. 
Generale de Med., No. 29 1, foot note. Also, Gazette de Sante No. 17. 



INTERMITTING FEVER. 109 

sometimes occurs in the commencement of intermitting fever ; for 
the blood recoils so powerfully from the external to the internal 
vessels, m the cold stage of the disease, that those who are, in other 
respects, predisposed to determinations to the head, are liable to 
suffer apoplectic oppression of the brain from this cause. Dr. Mac- 
cuUoch warmly opposes the opinion, that in apoplexies of this kind, 
there is any particular congestion of blood in the brain. The cases 
which I have myself seen, however, do not permit me to doubt that 
they were essentially comiected with cerebral pressure from inordi- 
nate vascular turgescence. It is not unlikely, however, that those 
apoplectic symptoms which occur as thie immediate consequence of 
the powerful influence of miasmata on the brain, independent of 
chills, or torpor of the vessels of the surface, are in no way depend- 
ent on cerebral compression from sanguineous congestion. 

Paralysis, neuralgia, mania, &c., as well as the above-named affec- 
tions of the alimentary canal, are, however, almost invariably direct 
malarious affections ; occurring with or without any manifest febrile 
phenomena ; and frequently exhibiting their affinity to intermitting 
fever, by their paroxysmal and strictly periodical character. For a 
full exposition of the nature, phenomena, and management of these 
miasmal diseases, the reader is referred to Dr. MaccuUoch's Treatise 
on Intermitting and Remitting Fever. 

But if intermitting fever has a tendency to produce other affections, 
it has been found also to remove various diseases of a chronic and 
obstinate character, Celsus observes, that intermitting fever is often 
remedial of itself (Lib. II., cap. 8, p. 70.) The tendency of quar- 
tans to cure epilepsy, is mentioned by Hippocrates ; (Epidem. 1;) and 
we are told that the celebrated mathematician De la Hire, was per- 
manently relieved of an habitual and most violent palpitation of the 
heart, by an attack of ague of the quartan type. (Academ. des Sci- 
ences, Pan. 1718. Hist., p. 110.) Fordyce states, that rheumatism, 
cutaneous eruptions, hysteria and indigestion, have been effectually 
removed by attacks of intermitting fever; and Vogel asserts, that 
he has known asthma and hypochondriasis cured by this disease. 
Almost all writers, however, attribute much more sanative power in 
this respect to quartans than to either of the other two types. 

Intermittents, when suffered to pursue their course without being 
controlled or embarrassed by external influences, appear to have a 
natural tendency to terminate spontaneously, after a certain number 
of paroxysms have been passed through. Quotidians, for instance, 
if they are simple and regular, will tend to terminate their course on 
the seventh day, and tertians on the fourteenth. Quartans will gene- 
rally run on to the sixth week. Of the natural tendency of the two 
former types to terminate at about the periods just indicated, I have 
the strongest conviction from my own observations. The disease 
may not generally terminate spontaneously at these periods, but its 
tendency to do so will be such, that if assisted by a proper febrifuge, 
it will not only more certainly be arrested, but a relapse will scarcely 
ever occur, unless the remote cause continues to act on the system. 
Every one who has had considerable experience in the treatment of 



110 INTERMITTING FEVER. 

intermittents, must have been struck with the great frequency of 
relapses, even where the patient has been removed out ot the sphere 
of the influence of the remote cause. From what I have observed 
in relation to this subject, I will venture to say, that it the usual 
febrifuges were withheld until after the seventh paroxysm, such an 
occurrence would, under all circumstances, be comparatively very 
rare. I have already adverted to the tendency of intermitting fevers 
to relapse at stated intervals; and although I cannot undertake to 
reconcile the apparent opposition in these statements, namely, that 
fevers of this kind tend naturally to terminate and also to relapse 
at the septenary periods, yet of the truth of the observation I enter- 
tain the strongest conviction. 

Prognosis. — The intermittents of temperate chmates are among 
the least dangerous of febrile affections. In hot latitudes, however, 
they often assume a highly malignant and fatal character. Death 
from a simple and mild intermittent does, nevertheless, sometimes 
occur ; and when this happens, it is nearly always in the cold stage, 
and with symptoms of apoplexy. I have met with two fatal instances 
of this kind. The violent internal congestions which occur during 
the cold stage, are well calculated to produce cerebral oppression and 
apoplexy, particularly hi persons who are naturally predisposed 
to this malady. In general much less danger is to be apprehended 
from this disease in the young, robust and vigorous, than in persons 
of feeble, nervous, and depraved habits of body. In individuals of 
the latter habit, there is sometimes not sufficient vital energy to react 
and develop the hot stage, and they occasionally sink into a state of 
lethargy or fatal apoplexy. The more irregular an intermittent is, 
in relation to its type and particular phenomena, the more difficult in 
general it is to eflect a permanent cure. Postponing agues are more 
favourable than such as anticipate their paroxysms. The latter tend 
to the continued form. A scabby and humid eruption about the 
mouth and nostrils is a favourable sign. When habitual discharges, 
whether natural or morbid, reappear after having been suppressed 
by the ague, perfect convalescence generally soon follows. The state 
of the digestive functions has an important bearing on the prognosis 
of intermittents. So long as digestion is performed with considerable 
activity, and there are no decided marks of gastric irritation, very 
little difficulty in general will be experienced in removing the disease. 
But when these functions are prominently deranged, and there are 
manifestations of much debility of the stomach, we may calculate on 
meeting with considerable difficulty in our effi^rts to prevent the re- 
turn of the paroxysms ; for even should a temporary stop be put to 
the progress of the disease, the liability to relapse in this state of tl.e 
digestive apparatus, is such as to render the best-directed treatment 
often abortive. 

Delirium seldom occurs in intermittents, and when it does happen, 
it must be viewed as unfavourable; and even more so than mere 
coma. In raahgnant intermittents, delirium is common ; indeed, it 
may be regarded as almost peculiar to the worst varieties of this 
disease. Difficult and oppressed breathing, attended with hiccoui:h 



INTERMITTING FEVEIl. Ill 

and frequent deep sighing, is a bad sign. Sydenham observes, that 
a tumid and hard abdomen, with sweHing of the tonsils, is in general 
indicative of a fatal termination. One of the most unfavourable 
signs is a profuse and prolonged colliquative and offensive diarrhoea. 
Bloody urine also is very unfavourable. The latter symptoms are 
ahnost exclusively confined to the violent intermittents of hot cli- 
mates. When, during the intermission, the patient remains very 
much debilitated and oppressed, and the feet and legs are oedematous, 
considerable danger may be justly apprehended. 

Tertians are, in general, more readily removed than quotidians, 
and quotidians than quartans. Intermittents not unfrequently change 
into the remittent form ; and this conversion is, of course, always an 
unfavourable occurrence. Wlien such a change is about to happen, 
the paroxysms of the intermittents are progressively prolonged until 
they run into each other. Simple tertians always reduplicate their 
type, before they assume the continued or remittent form. The 
conversion of the intermittents into the remittent form, is particularly 
favoured by whatever is capable of causing or augtnenting the gene- 
ral phlogistic condition of the system, and especially by the accidental 
supervention of some internal inflammation. The unseasonable em- 
ployment of tonics and stimulants is frequently productive of such 
changes in the form of the fever. 

Causes. — The only general cause of intermitting fever is koino- 
miasmata. Intermittents are the simplest, and in general the least 
dangerous of all the febrile diseases produced by this variety of mias- 
mata. In the vicinity of marshes, we may often trace the various 
grades of miasmatic fevers from the most violent and fatal to the 
simplest and mildest varieties, as we progressively remove from the 
focus of the deleterious exhalations towards the circumference of its 
influence. On the borders of the soil, whence the miasmata ema- 
nate, if very copiously engendered, continued and highly fatal cases 
of bilious fever will prevail ; at a greater or less distance from this 
point, mild remittents will predominate ; and at a still more remote 
situation, intermittents will be most common. From the same cir- 
cumstances, the first diseases which occur in miasmatic districts are 
generally intermitting fevers; as the season advances, remittents 
occur, and finally prevail with great violence ; as the cold weather 
approaches, and the extrication of miasmata begins to diminish, 
intermittents again become more common, and the remitting fevers 
gradually disappear. 

The tendency of koino-viiasmata to produce intermittents, is much 
enhanced by sudden changes of atmospheric temperature. Intermit- 
tents are never more prevalent than when the days are very warm, 
and the evenings and mornings cool and damp. In some instances, 
several weeks elapse between the reception or impressions of the 
miasm, and the occurrence of the fever. I have repeatedly known 
persons to be attacked with intermitting fever in this city, several 
weeks after they had been exposed to koino-miasmata in the coun- 
try.* Persons who have been exposed to miasmata, should carefully 

* Upon this point Dr. Macculloch differs so far as I know from every other 



112 INTERMITTING FEVER. 

avoid every thing capable of debilitating the system, and particularly 
the digestive organs, for at least two weeks after exposure. 

Although koino-miasmata may be regarded as incomparably the 
most frequent cause of intermitting fever, yet various other causes 
may, under favourable circumstances, give rise to this form of fever. 
Richter observes, that the worms and other causes of intestinal irri- 
tation have been known to produce intermitting fever. He mentions, 
also, suppressed catamenia, and hfcmorrhoidal discharge, as well as 
the drying up of old ulcers, as occasional causes of intermitting fever. 
I have seen one instance, in a delicate child, where a distinctly formed, 
ague was manifestly produced by intestinal irritation from too free 
an indulgence in irritating articles of food. An interesting case is 
related by Mr. Earle,* in which a regular intermittent was produced 
by the irritation of a small piece of dead bone in an old wound, and 
which was at once arrested on removing the irritating substance. It 
would seem that either the generation of miasmata, or their power of 
producing intermitting and remitting fevers, is greatly controlled by 
certain occult conditions, wholly unconnected with any appreciable 
circumstances, with regard to atmospheric temperature, or any of the 
other known requisites for the production of this poison. In certain 
districts of the temperate latitudes, malarious fevers will sometimes 
disappear, or become extremely rare for a number of successive 
years; and then gradually become more and more common, until, 
in the course of a few seasons, they assume the prevalence of an 
epidemic ; and yet no material difference will be obvious between 
these periods of exemption from, and prevalence of disease, in rela- 
tion to what are deemed the necessary concomitants for the produc- 
tion of miasmata. 

Proximate cause. — In relation to the proximate cause of this form 
of fever and of its periodicity, we may at once confess our entire 
ignorance; for all that has hitherto been advanced in relation to 
these mysterious subjects, amounts to nothing more, at best, than 
some ingenious conjectures and hypothetical speculations, with a 
great deal of crude and absurd reasoning and idle suppositions. As 
to the sentiments of Broussais, which place the proximate cause of 
this and all other fevers in an inflammation of the mucous membrane 
of the alimentary canal, it can neither be profitable nor interesting to 

writer who has attended to this subject. He maintains that the interval between 
the apphcation of the miasmata, and the first manifestations of its morbific eifects 
on the system, seldom, if ever, extends beyond twenty-four hours. <' I know not,"' 
he says, "if physicians have fairly observed that the supervention of intermitting 
fever may be later than twenty-four hours fi-om the exposure to the cause ;" and 
he asserts that the attack of intermitting, as well as remitting fever, "sometimes 
instantaneously follows the application of the poison." That the febrific powers of 
miasmata may be manifested verj- soon after they are applied, cannot be questioned, 
but the assertion that the period between the reception of the poison, and its obvious 
effects, does not probably extend beyond twenty-four hours, is undoubtedly con- 
tradicted by almost daily experience in our own climates. 
* Medico-Chir. Review, Januar)-, 1827. 



INTERMITTING FEVER. 113 

repeat again what I have already advanced in refutation of its cor- 
rectness. 

Treatment. — The treatment of intermittents nmst be considered 
under two distinct heads ; namely, that which is proper during the 
paroxysm; and that which is to be employed during the intermissions, 
and upon which the radical cure of the disease depends. 

In the ordinary regular intermittents of the temperate latitudes, re- 
mediate interference during the paroxysm of the disease is extremely 
uncommon, and is indeed very generally altogether unnecessary. 
Nevertheless, where the febrile excitement becomes very violent in 
the hot stage ; or where the system is so enfeebled that dangerous 
congestions and oppression occur during the cold stage, medicinal aid 
is not only proper, but sometimes absolutely essential to the safety 
of the patient. During the cold stage of an intermittent, the patient 
ought to be kept moderately warm ; and as the thirst is generally very 
urgent, bland and warm drinks should be freely allowed. In gene- 
ral, however, stimulating drinks, and the appfication of much arti- 
ficial heat, with the view of moderating the distressing sense of cold, 
are improper; since they very rarely lessen the feeling of chilliness, 
and tend often considerably to increase the violence of the succeeding 
hot stage. These observations apply to the regular disease, occurring 
in individuals of sutiicient vital energy to develop the hot stage, with- 
out any artificial support. When die patient is feeble, nervous or 
exhausted, it will, generally, be beneficial to aid the vital powers 
during the cold stage, both by external and internal exciting agents, 
more especially, by the application of external heat. Without such 
aid, the cold stage will probably be greatly prolonged, and the sj^s- 
tem so oppressed, by internal congestions, as to prevent the regular 
development of the subsequent stages. 

Various means have been adopted for the purpose of curtailing the 
cold stage; and of these, emetics and opium appear to be the most 
efficient. An emetic administered at the begiiming of this stage, 
will frequently put a speedy termination to its progress; and a full 
dose oi opium, i^ken a short time before the expected occurrence 
of the chills, will generally have the same good effect. This latter 
remedy was particularly recommended by Dr. Trotter; and other 
eminent physicians have given their testimony in its favour. In 
debilitated and relaxed habits the exhibition of a grain or two of this 
narcotic, just before the accession of the chills, will generally prove 
decidedly beneficial. I have frequently resorted to it in cases of 
this kind, with obvious advantage. In persons of a full and vigorous 
habit of body, it will rarely do any good, and may readily do mischief 
by increasing the violence of the reaction and of the determination to 
the brain, in the hot stage. Compression with the tourniquet, also, 
was some years ago strongly recommended to the profession, for 
arresting the cold stage of intermittents, by Dr. Kellie.* 1 have 
known it to be employed in four cases, and although the effects of it 

* Medical Commentaries for the years 1794-1797, by Dr. Duncan, of Edin- 
burgh. 

VOL. I. 8 



114 INTERMITTING FEVER. 

were bv no means equal to those which Dr. KcUie ascribes to it, 
there was, nevertheless, a manifest impression made on the violence 
and progress of the chills. Dr. Kellie asserts, that by obstructing 
the circulation in an upper and in a lower extremity, by means of a 
tourniquet, we may, in general, stop the cold stage in three minutes ; 
and that if the compression be made immediately previous to the 
accession of the cold stage, it will be entirely prevented. The limited 
experience which I have had in relation to this practice, does not 
confirm this very favourable account of its effects ; although some, 
and occasionally perhaps considerable advantage may, no doubt, be 
obtained from it. I should apprehend, however, that in vigorous 
and plethoric subjects, considerable danger must attend this practice, 
from tiie tendency which it must have to favour vascular turgescence 
of the brain ; and thereby dangerous oppression or apoplexy. 

Within the last two years, Dr. Mackintosh has published some 
highly interesting observations on the utility of blood-letting in the 
cold stage of agues, which, though contrary to the sentiments uni- 
versally entertained concerning the character of this stage of febrile 
development, and the known tendency of blood-letting, are never- 
theless too strongly confirmed, by well attested facts, to justify us 
in rejecting them, without further experience. "There are few 
things," says a late writer, <' more repugnant to the imagination of 
a medical man than that of venesection in the cold stage of inter- 
mittents. Books and lectures all inculcate a diametrically opposite 
practice. We see the face and the surface of the body pale and 
cold ; the pulse feeble and quick ; the teeth chattering ; the whole 
body shivering; and the suffering patient huddling himself up in all 
the clothes he can find to keep the spark of life from being extin- 
guished ! The very idea of abstracting the vital fluid, which seems 
almost entirely to have vanished, is horrible. But yet, when we 
come to reflect that the blood has only shifted its place from the 
circumference to the centre, and that the internal vessels and organs 
must now be gorged with this fluid, and as it were in a state of 
suflbcation, there is nothing very incongruous in the attempt to relieve 
the suffering organs by abstracting a portion of blood from the gene- 
ral circulation." Moreover when we advert to the circumstance that 
blood-letting has been strongly recommended and successfully em- 
ployed to remove the internal congestions which occur in typhiis 
fevers, where there is generally an actual deficiency or impairment 
of the vital energies, it does not appear so very extraordinary, that 
the same means should be adequate to restore the equilibrium of the 
circulation, or to remove the internal congestion in an ague, where 
the vital powers are not impaired, but only oppressed. Dr. Mackin- 
tosh states, " that he has seen men in the most severe sufferings from 
the chills relieved after the abstraction of six, eight, and ten ounces 
of blood; and he has known three ounces to suffice. The relief, 
which is the most perfect relief that can be conceived, is so sudden, 
when a good orifice is made, that it has surprised and delighted every 
one who has seen this practice." Dr. M. had this practice tried on 
himself in 1810; and, although bark and other remedies had entirely 



INTERMITTING FEVER. 115 

failed, he found that before twelve ounces of blood had been drawn, 
"the rigors ceased with ail their unpleasant accompaniments," and' 
neither the hot nor the sweating stage ensued. "A pleasant sense 
of heat succeeded the painful one of cold ; and instead of weakness, 
he was sensible of an acquisition of strength." He afterwards bled 
many other patients in the cold stage of this malady, and uniformly 
with the same favourable results. This practice was put in operation 
in the Royal Ordnance Hospital, of Edinburgh, in the presence of 
many medical gentlemen, and must, therefore, be regarded as amply 
attested.* In a single instance I have drawn blood, in the cold stage 
of this disease ; and in this case, it moderated the violence of the chills 
and curtailed their duration in a manifest degree. I have not since 
had a favourable opportunity of repeating this practice, but from the 
result of this case, and the strong testimony of Dr. Mackintosh, I feel 
inclined to give it a further trial, whenever an opportunity of doing 
so shall present itself. It cannot be presumed, however, that this 
practice is equally well adapted to all cases. Dr. Zabriskie, of New 
York, states that he found it, in general, decidedly beneficial in per- 
sons " of a plethoric, full habit, with strong pulse, and not enfeebled 
by intemperance or by the fever." In patients enfeebled by intem- 
perance, or the long continuance of the fever, with a small and weak 
pulse, bleeding in the cold stage sometimes gives rise to alarming 
symptoms.t 

In the liot stage, it sometimes becomes necessary to moderate the 
violence of the febrile excitement, especially when delirium or alarm- 
ing local determinations take place. Blood-letting is of course the 
most direct and elBcient means for this purpose, and where the indi- 
cations for antiphlogistic measures are strong, it ought to be promptly 
employed. In agues of a decidedly phlogistic diathesis, blood-letting 
during the hot stage will often contribute considerably to the success- 
ful employment of the bark in the intermission, I have sometimes 
known the bark promptly efficient in arresting the disease, after a 
copious blood-letting during the paroxysm, where it had previously 
failed. In cases attended with a very hot and dry skin, and a full 
and vigorous pulse, cool, bland and acidulated drinks are both grateful 
and salutary. A draught of cold water while the skin remains dry, 
will often speedily subduct the febrile heat and predispose to perspi- 
ration. It may also be proper, in instances of very high general fe- 
brile excitement, to exhibit some of the refrigerant diaphoretics — 
such as nitre — antimony — the saline effervescing mixture.^ As soon, 
however, as the skhi begins to be moist, cold drinks must be with- 

* Ed. Med. and Surg. Joum., April, 1827; and Medico-Chir. Rev., July, 1827, 
page 186. 

t Amer. Journ. of Med. Scien. vol. xiii, page 80. 
X The following mixture is an excellent reniedy for this purpose — 
R. — Spirit Mindereri, ^iv. 
Spirit. Nitr. Dulc. gii. 
Via. Antimon. gi. 
Syrup Limonis, §i. — M. Take a tablespoonful every hour. 



116 INTERMITTING FEVER. 

held. During the last or sweating stage, we ma^^ allow tepid drinks 
of a bland character freelv. 

When the stomach is extremely irritable— giving rise to irequent 
and violent vomiting, in the cold or hot stage, tepid diluents should 
be ?iven, until there is reason to think that the bile is discharged. 
Opium is, perhaps, our best remedy for checking excessive vomiting 
in this disease. This article does not often aggravate the violence of 
the reaction, when given in the hot stage, as might be apprehended. 
Indeed, Dr. Lind zealouslv advocates the propriety of exhibiting a 
full dose of opium, soon after the hot stage is developed, as a general 
practice. He asserts that it takes ofl' the burning heat of the fever, 
hastens the accession of the sweating stage, and often produces a soft 
and refreshing sleep, from which the patient awakes free from all 
complaints, and in full perspiration. He thinks, moreover, that the 
use of opium in the hot stage tends to obviate dropsy and jaundice. 
I have given opium in the hot stage to check vomiting, and have 
always found it to answer this purpose very promptly and completely, 
without any unpleasant consequences. 1 cannot, however, think 
that opium is a proper remedy in the hot stage of ague, unless it be 
in broken down constitutions, or in such as are feeble and exhausted 
by previous injurious influences — or unless it be employed to remove 
some accidental atiection of a distressing or dangerous character. 
In cases where the reaction of the heart and arteries is incomplete, 
and where much internal congestion continues to exist through this 
stage, opium is, without doubt, a valuable remedy. To put a stop to 
excessive vomiting in this, as well as in other diseases, not attended 
with phlogosis of the mucous membrane of the stomach, I know of 
no medicine which is more promptly and certainly effectual than a 
solution of camphor in sulphuric aether, in the proportion of two scru- 
ples of the former to an omice of the latter; of which twenly or 
thirty drops may be given with about ten grains of calcined magnesia 
every half hour until the vomiting is arrested. I have rarely found 
the second dose necessary. 

Whatever advantage may result from remediate treatment durins^ 
the paroxysm, universal opinion concurs in regarding the intermis- 
sion as the proper period for the safe and certain radical treatment 
of intermitting fevers. In prescribing for the radical cure of inter- 
mittents, it is of no small consequence to attend to the particular cha- 
racter of the disease in relation to the four modifications or varieties 
mentioned above ; for each of these requires some peculiar modifica- 
tions of treatment. 

1. The inflammatory variety, as has already been stated, is marked 
by symptoms during the intermission, which indicate an irritated and 
phlogistic condition of the system, incompatible with the salutary in- 
fluence of the bark and the other febrifuge remedies of this kind. In 
this modification of the disease a strictly antiphlogistic treatment 
must precede the employment of the tonics usually resorted to. The 
patient must be put on an antiphlogistic regimen ; one or two cathar- 
tics composed of calomel and jalap — or calomel succeeded in a few 
hours by an ounce of Epsom or Glauber's salts, will be proper- and 



INTERMITTING FEVER. 117 

where the inflammatory diathesis is very conspicuous, blood-letting, 
nitre, antimonials, &c. are often indispensable. In cases of this c}ia- 
racter, blood-letting will, in general, prove most efficient in reducing 
the phlogistic habit, when it is practised pretty copiously during the 
hot stage. In cases of vernal intermittents, in which the bark or 
quinine had failed in consequence of the general irritated and phlo- 
gistic condition of the system, I have succeeded perfectly with these 
febrifuges, after the patient had taken one of the following powders,* 
every two hours during an intermission, and a small bleeding in the 
hot stage of the succeeding paroxysm. 

In the cojiizestive and iiialignant varieties of ague, it will seldom 
be proper to lose much time in preparing the system for febrifuge 
tonics. In such cases, the powers of the system must be economized, 
and tonics early and liberally resorted to. In the gastric modification, 
which is most commonly met with in the temperate latitudes, there 
exists obvious indications of gastric impurities and disorder — such as 
nausea; bilious vomiting and purging: foul tongue; loss of appe- 
tite ; pains in the stomach and bowels ; bitter or depraved taste, &c. 
In intermittents of this character, it will be peculiarly proper to attend 
to the state of the alimentary canal, before the bark or tonic remedies 
are resorted to. Mild mercurial purgatives are generally decidedly 
beneficial. In some instances, it may be necessary to repeat them 
several times before the bowels are brought to a proper state for the 
employment of febrifuges. Emetics, too, will often contribute much 
to the success of the bark or quinine. In intermittents of a well- 
formed inflammatory character, there are seldom any unequivocal 
manifestations of gastric impurities, and hence these evacuations are 
much less useful or important in them than in the variety I have 
termed gastric. 

Among the various articles which have been recommended for 
the cure of intermittents, the Peruvian bark and its pr&parations, is 
unquestionably by far the most important. Within the last ten 
years, the sulphate of quinine has, in a great measure, taken place 
of the bark in substance, and in many respects, this preparation 
possesses important advantages over the crude material. It has in- 
deed been said, that the bark itself will sometimes remove the disease 
where the quinine has failed ; but the converse may be said with 
equal correctness; for I have in several instances succeeded with the 
latter, after the former had been used in large doses without success. 
Mr. Valpes, of Naples, in a recent communication to the French 
Royal Academy of Medicine, states, as the result of his inquiries, 
that the sulphate nf quinine is preferable to the cinchona, in inter- 
mitting fevers, whilst the latter is preferable in the fevers formerly 
denominated putrid,\ and which are produced by idiomiasmata.J 

* R. — Pulv. nilrat. potassa? ^iss., pub', doveii. gr. vj., culom. gr. vj. M. — In chart. 
No. vj. dividend. 

t Revue Medicale, Mai, 1828, p. 306. 

Jin March, 1825, the number of lunatics brought to the Mnison iVAvcrsa in the 
kingdom of Naples, was so great, tliat it was found necessary to lodge them in a 



lis INTERMITTING FEVER- 

From mv own experience, I have not been led to think that there 
exists any essential difference in the febrifuge virtues of these two 
remedies; but as the quinine is much less nauseous, and can be 
given in sufficient doses in a very small bulk, I should, Irom these 
advantages, ahvays prefer it to the bark in substance, unless some 
idiosyncrasy exist against its influence, which can be ascertamed 
only by experience. 

Much difference of opinion has been expressed, both m relation to 
the period of the disease, and the particular time of the intermission, 
at which the bark may be most effectually administered in this form 
of fever. It has been contended, that it will generally be much 
better to suffer several paroxysms to take place, before any attempt 
is made to arrest their recurrence. Recamier has recently advocated 
this practice, as both the most effectual and the safest to the future 
health of the individual. I do not at all doubt the correctness of 
this mode of management. Unquestionably, a great majority of our 
ordinary agues maybe immediately arrested, and with perfect safety, 
by giving the bark, during the first or second intermission ; but in 
this case relapses are much more common than where the disease 
has been suffered to run on to the fifth or seventh paroxysm, I 
have found agues arrested after the first or second paroxysm, re- 
lapse again and again, until they were suffered to run on to the fifth 
or seventh day, when a few doses of quinine put a permanent stop to 
their progress. It has long been my practice, when I have met with 
relapsing agues, to suffer them to run on through five or seven par- 
oxysms, before any attempt was made to arrest them, and I have 
invariably found this plan permanently successful. In cases which 
require preparation, especially in inflammatory intermittents, delay 
is, of course, essential, before the bark can be employed with pro- 
priety. I would not, however, lay it down as a general rule, that 
the disease should be suffered to run on through five or seven par- 
oxysms ; for where the apyrexia is very complete, and the patient 
experiences no feelings of illness during the intermissions, the bark 
may almost always be given with complete success, as soon as the 
bowels are evacuated by a suitable cathartic* In instances of an 
opposite character, or such as have shown a tendency to return after 
a week or two, it will be very difficult to put a final stop to the par- 
oxysms, if the febrifuge be employed during the first or second inter- 
mission. A case came under my notice, during the preceding 
autumn, which had already relapsed four times, and always punc- 

convent, which was not properly prepared to receive them. The most filthy of 
these unfortunate beings were put into a small domiitory, which was in a state of 
extreme filthiness. A fever soon broke out among them, which was at. first 
regarded as a petechial fever, and was treated by antiphlogistics. The disease 
made a rapid progress, and became unusually fatal. The sulphate of quinine 
was finally employed, but this appeared rather to aggravate the symptoms, than 
to afford any advantage. At last, the hark in substance was given, and immediately 
resulted in the happiest effects. — Revue Medicate, Mai, 1828, p. 306. 
* R. — Pulv. jalap . . . Calomel aa. gT. x. M. 



INTERMITTING FEVER. 119 

tually on the seventh day. After each relapse, the patient took 
.quinine in full doses, which always arrested the disease for the short 
period mentioned. When he applied to me, I advised him to suffer 
his disease to go on for some time, without any other medicine than 
a mild purge every other day. He did so ; and on the ninth day, 
the disease left him spontaneously and permanently. 

The foregoing observations apply, of course, to the regular inter- 
mittents of the temperate latitudes ; for in that rapid and fatal variety, 
which is termed malignant, no time should be lost by preparatory 
measures, but immediate recourse had to large and frequent doses of 
the bark, as soon as a favourable intermission occurs. The same 
rule applies to the disease occurring in very feeble, nervous, and ex- 
hausted subjects ; for unless it be speedily removed, the system may 
sink under the repeated shocks of the paroxysms. 

With regard to the particular period of the intermission at which 
the bark may be most successfully given to arrest the succeeding pa- 
roxysm, a diversity of sentiments have been expressed by writers. 
Some have advised its employment in large doses immediately after 
the sweating stage has passed off; whilst others recommend it to be 
given largely, " as near to the time of the expected paroxysm as the 
condition of the patient's stomach will allow." (Cullen.) There are 
others, again, who think it best to exhibit the bark in divided and 
frequent doses, throughout the whole period of the intermission. (For- 
dyce.) A few years ago, Dr. Ridgway published some cases, which 
go to show, that one large dose of cinchona given as near as possible 
to the commencement of the approaching paroxysm, will as certainly 
avert the paroxysm, as when given in repeated doses throughout the 
intermission.* Since Dr. Ridgway's publication. Dr. Brown, of Bos- 
ton, has published a small work, in which he adduces testimony of a 
similar purport.t According to Dr. Brown's experience, two or three 
grains of the quinine taken just as the first symptoms of the ap- 
proaching paroxysm are experienced, will, when followed up at in- 
tervals with a second, third, and sometimes a fourth dose, almost 
invariably put a stop to the disease. When given just as the cold 
stage commences, "its influence over the rising symptoms becomes 
manifest in a few minutes ; the pulse becomes more full and distinct ; 
the respiration more easy ; the skin acquires its natural temperature, 
and, in eleven minutes in his own case, not one unpleasant symptom 
remained." This state, however, generally continues but a short 
time, and it becomes necessary to repeat the dose, sometimes three 
and even four times before the paroxysm is subdued. Dr. Ridgway 
gave an ounce of the bark at once, as soon as the premonitory symp- 
toms of the paroxysm were felt, and always found it to prevent the 
attack. There can be no doubt that the disease may be speedily ar- 
rested in this way ; but it may be reasonably questioned, whether it 
possesses any real advantage over the plan of exhibiting this febri- 
fuge in efficient doses during the latter period of the intermission. I 

* London Medical and Physical Journal for April, 1825. 

t A Treatise on repelling the Paroxysm of Intermitting Fevers. Boston, 1836. 



120 INTERMITTING FEVER. 

have generally prescribed the quinine in two grain doses every hour, 
commencing about six hours before the beginning of the approachmg 
paroxysm ; and I have had no cause to be dissatisfied with the con- 
sequences. Indeed, I have reason to apprehend that a large dose of 
quinine given during the chills, is calculated to produce very disagreea- 
ble effects. In two instances, one a delicate married lady, and the 
other a lad about twelve years old, a most singular and raving spe- 
cies of maniacal affection ensued ; apparently from taking large doses 
of this medicine ujLer the chills had commenced. In both instances 
this alarming mental disturbance contuiued for several hours. I may 
be wrong in ascribing it to the cause here assigned, but the circum- 
stances strongly favoured the suspicion. 

Whatever views we may adopt, with regard to the time at which 
it may be best to begin with the bark or quinine, there can be no 
doubt concerning the propriety of giving large doses,* in such a man- 
ner as to make a decisive impression on the system in the latter period 
of the intermission. I am well satisfied that two or three large doses 
— three grains of the quinine, given two or three hours before tlie pa- 
roxysm, will do more towards averting it, than a larger quantity ex- 
hibited in small doses throughout the whole interval of the apyrexia. 
In relation to the propriety of employing emetics and cathartics as 
preparatory measures for the use of the bark, authors express contra- 
ictory opinions. Unquestionably, where the signs of gastric impuri- 
ties are conspicuous, and there exists no urgent necessity from the 
nature of the case, to arrest the disease promptly, it will be proper to 
evacuate the alimentary canal previous to the employment of the 
bark. These evacuations will also be useful in cases where the 
inflammatory habit is so strong as to prevent a complete apyrexia. 
Nevertheless, in the ordinary cases of the disease, where there are 
no signs of a loaded state of the bowels, and the apyrexia is very 
complete, the bark may be successfully employed without either pre- 
vious purgation or emesis. Upon the whole, however, I should in 
all instances of this disease, not attended by malignity or great pros- 
tration, prefer one or two mild cathartics, before the bark is taken, for 
the reasons already mentioned. 

Tlie Peruvian bark has been frequently accused of having a ten- 
dency to produce visceral indurations and other unpleasant conse- 
quences ; such as rheumatism, dropsy, &c. This accusation is, how- 
ever, wholly unfounded. No doubt, indeed, can exist that these and 
other injurious consequences may be produced by the injudicious 
employment of this remedy. Wiieu given, for instance, in agues, 
attended with strong marks of an inflammatory condition of the sys- 
tem, without proper antiphlogistic preparatory measures, we can rea- 
dily conceive that the bark would favour the natural tendency of such 
cases to terminate in these disorders. In this respect, however, the 

* If the bark in substance be employed, not less than two drachms ouo-ht to be 
administered at each dose. Such doses taken at intervals of an hour or an hour 
and a half, within the last five hours of the intermission, will, perhaps do all that 
CAXXi be effected by bark in this disease. 



INTERMITTING FEVEK. 121 

bark does not differ from other tonic and stimulating remedies ; for 
It IS not by any thing pecuhar in the bark that these effects are pro- 
duced, but simply by the power it possesses, in common with the 
majority of febrifuge remedies, of favouring the phlogistic diathesis, 
and the progress of obscure inflammations. 

The bark is now generally given by itself. Formerly it was cus- 
tomary to give it in conjunction with various other remediate articles 
which were thought to augment its febrifuge powers. It is extremely 
doubtful, however, whether any combinations can materially improve 
its virtues ; and unless some particular circumstance be present which 
may render the use of other remedies proper, or unless the bark by 
itself produce unpleasant or injurious elfects on the alimentary canal, 
it will probably be best to employ it singly. When it causes much 
constipation, it may be usefully given as follows : 

R. — Pulv. cinchon. condam. ^j. 

rhei. ^ss. 

muriat. ammonia gj. — Ivlisce. In chart. Xo. iv. dividendae. One to 

be taken every hour or two. 

When the bark purges, it should be given with small portions of 
Dover's powder, or opium. The former, especially, acts beneficially 
in such instances, five grains of which may be given at each dose. 
Alkaline remedies become necessary in cases where there are signs 
of much acid in the stomach. The subcarbonate of potash is an 
excellent adjuvant to the bark in cases of this kind. From ten to 
twenty grains of the alkali may be given with each dose of the bark ; 
and to prevent this from acting on the bowels, which it is apt to do, 
it is generally necessary to make a triple compound— viz., bark, sub- 
carbonate of potash, and opium, or what is better, confectio opii. 
When the stomach is irritable, the bark will generally be speedily 
rejected. In this case we may sometimes cause it to be retained by 
uniting it with some aromatic substance, such as serpentcwla, or 
cloves, or mitmeg, or the calamus arornaticiis. The serpentaria 
is, perhaps, the best aromatic adjuvant to bark, where the stomach 
is too weak to retain it singly. 1 have, however, always found small 
doses of opium to answer better than any other remedy for this 
purpose. The addition of powdered black pepper answers extremely 
well in cases where the vomiting arises simply from gastric debility. 
Where, however, this occurrence depends on a highly irritated con- 
dition of the mucous membrane, neither this nor any other aromatic 
can be proper. In this condition, indeed, the bark itself cannot be 
employed until the gastric irritation is subdued by leeches, blisters, 
or cupping over the epigastrium. 

The employment of the quinine is much less apt to produce the 
inconveniences just mentioned than the bark in substance; but even 
this preparation will sometimes produce violent purging or vomiting 
— several very violent instances of which I have encountered in my 
practice. Formerly it was customary to employ the decoction, or 
the tincture, or what is better, both in union with each other, where 
the bark in substance could not be conveniently administered, or 



122 INTERMITTING FEVER. 

where the stomach rejected it. Since the introduction of the quttiine 
into practice, however, this mode of exhibiting the cinchona has 
been but Uttle employed ; nor does it appear probable that any cir- 
cumstances can occur which may not be as well met with this very 
convenient and concentrated preparation, as with either the decoc- 
tion or the tincture of the bark. The most convenient and elegant 
formula for exhibiting the quinine, is, perhaps, the following : 

Be- — Sulphatis quinsegr. xvj. 
Elixr. vitriol gtt. xvj. 
Syrup, limonis gj.— M. Dose, ateaspoonful every hour or two for an adult. 

As this mixture, though a very neat and concentrated one, is some- 
times much objected to on account of its bitterness, especially by 
children, I have generally prescribed it ac(?ording to the following 
formula, by which almost all the bitterness is wholly removed : 

R. — Sulphat. quina; gr. vj. 
Elixr. vitriol gtt. x. 
Pub. extract, glycyrrh. ^iss. 

Aq. fontanae gij. — M. Dose, a teaspoonful for a child between two and 
five years of age. 

In cases of ague, which, from long continuance, or from some 
previous malady, are attended with visceral indurations or enlarge- 
ments, the quinine or bark must be given, either after a gentle mer- 
curial course, or in conjunction with mercurial remedies. The blue 
mass will in general answer best for this purpose, as it is mild, and 
less apt to pass off by the bowels than calomel. In many instances 
of this kind, the bark will, in fact, fail entirely in putting a stop to 
the continuance of the disease; and I have known it to do manifest 
mischief even when given in conjunction with mercury. In such 
cases, mercury is the appropriate remedy ; and, under careful man- 
agement, will rarely fail to arrest the disease. From three to five 
grains of the blue mass, taken thrice daily, until the gums become 
slightly affected, will generally suffice to remove the complaint. 

Besides bark and its preparations, a vast variety of other reme- 
dies, drawn both from the mineral and vegetable kingdoms, have 
been employed with success, in the treatment of intermittents. As 
nearly all of them are, however, confessedly inferior to the cinchona, 
it will be sufficient here, barely to mention them. The most efficient 
of these articles are the following : viz., the barks of the dn^-wood 
(cornus florida) ; of the American tulip poplar, (Liriodendron tulipi- 
fera) ; of the horse-chestnut, (E. hippocastanum) ; of different oaks ; 
of different species of willow; the Virs;inia snake root ; colomhu ; 
gentian; quassia, Sic. Coffee is highly recommended by Grindel ; 
given in doses of from fifteen to twenty grains every hour, it is said 
almost invariably to arrest the disease. (Richter). The black, or 
cellar spider's iveb, is highly recommended by Dr. Robert Jackson,* 
as a remedy for intermittents. He is of opinion, "that it prevents 

* London Medical and Physical Journal, vol. xxi. 



INTERMITTING FEVER. 123 

the recurrence of the intermittent paroxysms more abruptly and more 
efiectually than even bark or arsenic." I have employed this article 
in six cases; two of these were speedily cured, the others resisted 
its powers entirely. Shrader speaks of this article as an effectual 
remedy for agues, in his Dispensatory, published as early as 1G44. 
It certainly possesses very considerable powers in allaying morbid 
irritability, and in calming the excitement both of body and mind. 
In my own person, it produces the most delightful state of mental and 
corporeal tranquillity, far exceeding that which is caused by opium.* 
It is given in five or six grain doses every three or four hours. The 
nniridte ofainmonia is favourably mentioned by Richter as a remedy 
in this diseaseut He considers it especially useful in agues attended 
with gastric impurities, or a loaded state of the bowels; and in cases 
connected with viceral indurations. It should be given in union 
with quinine or. cinchona in substance. I have used it myself, in 
cases attended with induration and enlargement of the spleen, and 
with the most favourable effects. The muriate of ammonia is, per- 
haps, the most powerful remedy we possess for resolving indurations, 
when given in very large doses internally. In Germany, it has of 
late years been much and very successfully used in enlargements of 
the prostate gland, and other similar affections. In my own practice, 
I have had the most satisfactory proofs of its very excellent powers 
in this respect. I have given it to the extent of three drachms daily. 
In intermittents, with indurated spleen, it may be given in combina- 
tion with quinine, in the proportion of twenty grains of the muriate 
of ammonia to two grains of the latter. The former ought to be 
continued after the quinine may no longer be necessary — that is, 
after the paroxysms have been arrested. Salicia has recently been 
much extolled for its excellent febrifuge powers. It is given in 
doses of from twenty to forty grains. M. Miquel has published aii 
account of its use in this disease, from which it would appear that 
it is little, if in any degree inferior to the qidnia in intermittents. 
It has also been used by Dr. Gerardin with marked success. Other 
physicians in France and Italy have employed it for the cure of in- 
termittents, with satisfactory results. Dr. Berti, the erudite editor of 
Burserius's posthumous works, speaks very favourably of its febrifuge 
virtues.^ 

Among the mineral preparations, arsenic is undoubtedly, the most 
efRcicMt, with the exception,perhaps, of the sulphate of zinc. Arse- 
nic was employed in this disease near a century ago, by Jacobi;§ but 
it was not till Fowler and Brera published their experience, in relation 
to its medicinal powers, that it was brought into general notice as a 
remedy in agues. It is, unquestionably, a very efficient remedy in 
this disease ; but, in individuals of a cachectic habit, or where there 

* Eberle's Therapeutics, vol. ii, p. 121, first edition, 
t Specielle Therapie, vol. ii. 

X North Amer. Med. and Surg. Jour., vol. x. p. 192. 

^ De Arsenico sale alcalico domiti usu interno salutari. — Acta Acedera. Elet. 
Mogunt.; torn. i. p. 116. 



124 INTERMITTING FEVER. 

is a scorbutic tendency, it is apt to cause dropsical effusions, as well 
as great debility and symptoms of a general depravation of the sys- 
tem. It appears, moreover, to be improper in phthisical constitutions, 
and where a strong phlogistic tendency prevails. Of the tendency 
of arsenic to produce anasarcous effusion, I have had a strong illus- 
tration within the present year. I prescribed Fowler's solution to a 
syphihtic patient, and, although his nodes and nocturnal pams were 
removed, he became universally anasarcous. Arsenic appears to be 
best calculated to remove this disease without detrimental conse- 
quences, in individuals of a firm and vigorous constitution. The 
usual mode of prescribing it is in the form of Fowler's solution, or 
the liquid arseniate of potash. From eight to twelve drops may be 
given every four or five hours during the intermission. I have gene- 
rally given it in substance in union with opium, formed into pills in 
the proportion of one-tenth of the oxide of arsenic, to one-fourth of a 
grain of opium every three or four hours during the apyrexia. 
Bielfs arseniate of ammonia is, I think, decidedly the best arsenical 
preparation for internal use. Since the publication of the first edition 
of this work, I have employed this arseniate in various affections — 
particularly in an instance of periodical neuralgia, and in several in- 
stances o{ herpes, with peculiar advantage.* 

The sulphate of zinc is an excellent remedy for the cure of inter- 
mittents. I have very rarely failed to arrest the disease as promptly 
with it as with quinine. Dr. Firth, in a letter to Dr. S. Mitchell, of 
New York, dated Calcutta, 1805, speaks in the most favourable terms 
of this article as a remedy in intermittents. He asserts, that while 
prescribing in the Philadelphia Dispensary, he found it to cure cases 
in which both the bark and the arsenic had failed ;t Mr. Brand also 
observes that, " in the cure of intermittents, the sulphate of zinc is 
an admirable tonic," He gives the following formula for using it: 

R. — Zinci sulphatis^ gr. ij. 
Aq. cinnamon. 

destillat. aa ,f jss. 

Tinct. calumbae^j. — M. Fiat mistura. A tablespooful is to be taken every 
three or four hours. 

I have hitherto usually employed it according to the following 
formula : 

* This preparation is made by dissolving one part of the oxide of arsenic in 
four parts of nitric acid, with half a pint of muriatic acid. This solution is then to 
be saturated with carbonate of ammonia. The supernatant fluid must be slowly 
evaporated until the crystals of the arseniate of ammonia are formed. One grain 
of this salt is to be dissolved in an ounce of distilled water, to which a small por- 
tion of the compound tincture of lavender may be added. Of this solution, from 
thirty drops to one drachm may be given, in divided doses, in the course of twenty- 
four hours. — Casper"s Charakteristik der Franz. Med., p. 204. 

t New York Medical Repository, 1806. 



INTERMITTING FEVER. 125 

R. — Sulphat. zinci, gr. x. 
Pulv. capsici. ann. 3ij. 

Conserv. rosar. q. p. — M. In pil. No. xl. divid. S. One to be taken every 
two hours during the intermission. 

Black pepper, also, is strongly recommended by Dr. L. Frank for 
the cure of intermittents; and my own experience has afforded me 
several examples of its usefulness in this way. It is given in doses 
of from five to ten grains every two or three hours, either alone, or 
in combination with some of the bitter tonics.* 

Tartar emetic has recently been successfully employed in inter 
mittents by Recamier, at the Hotel DieiiA Out of seven cases, five 
were quickfy cmed by tartar emetic given in ptisans, so as to produce 
both emetic and purgative effects. This article has also been em- 
ployed externally with complete success in this disease. Dr. Pommer 
states, that in the winter of 1815, he was frequently disappointed 
with the use of the cinchona, in the intermittents which occurred in 
the army of Wurtemburg, encamped on the Loire and AUier. Ob- 
serving " that the fever generally disappeared on the eruption of 
pimples or pustules on any part of the body," he was induced to try 
what an artificial eruption would do towards curing those cases that 
had resisted the regular treatment. He accordingly directed frictions 
with the tartar emetic ointment on the epigastrium, and found it 
successful in every case as soon as the pustules appeared.^ 

There are few diseases over which the imagination exercises a 
more powerful controlling influence than intermitting fever. In all 
countries and ages this malady has been peculiarly favourable to the 
extravagant pretensions of superstition and imposture. Amulets and 
the most absurd practices have been always more or less in vogue, 
among the common people, as means for arresting the progress of 
this disease ; and the reality of a mysterious power in these spells, is 
sufficiently demonstrated to the minds of the vulgar, by the occasional 
disappearance of the disease under their occult influence. 

So intimate and strong, indeed, are the relations which subsist 
between the physical and moral elements of our nature, that there 
are few, if any diseases, in which we may not derive important 
advantages, from calling to our aid the invigorating powers of hope, 
or dissipating the depressing emotions of sorrow and fear, and diverting 
the mind from the causes, phenomena, and probable consequences 
of the disease, to objects of a more pleasing and hope-inspiring cha- 
racter. 

Any strong mental emotion occurring shortly before the usual 
period of the paroxysm will sometimes be sufficient to prevent its 
accession. It is especially, however, that condition of the mind 
which constitutes faith, or strong belief — and which the ignorant fre- 
quently yield to the most absurd practices, that opposes the strongest 
and most efJectual barrier to the progress of this and other periodical 

* Journal Complement, du Diction, des Sciences Med. N. 22. 
t Revue Medicate for December, 1826. 
X Jouro. der Praktischen Heilkunde, 1823. 



126 INTERMITTING FEVER. 

affections. Dr. MaccuUoch asserts, however, that the curative effects 
of moral influences of this kind, are almost entirely hmited to prunary 
attacks, "or those which have, at least, not relapsed often; and hii 
adds, that they are very seldom successful except m cases where all 
the circumstances of the disease are regular. 

The periodical affections, mentioned under the head of anomalous 
or masked agues, often disappear spontaneously after having con- 
tinued for some time. This is particularly the case with the periodi- 
cal neuralgic affections arising from the influence of miasmata. In 
some instances, however, they assume a persistent course, and yield 
only to proper remedial impressions. In general, the most efticient 
remedies for the cure of these affections are the same that are most 
effectual in regular intermittent fevers. A few full doses of quinine 
are suflicient often to remove periodical hemicrania, tic douloureux, 
or sciatica, without any other auxiliary remedies.* In some instances 
of this kind, arsenic is peculiarly beneficial. Dr. MaccuUoch, in 
reference to the use of bark and arsenic in these affections, observes, 
" that there are two leading circumstances under which they often 
disappoint us. This happens when the attacks of the disease are 
very irregular; and, secondly, when the disorder is of very long 
standing; while in exact correspondence with intermittents, these 
two states are very commonly united." In such irregular forms of 
miasmal disease, a " single blood-letting will sometimes render the 
type regular," and this being effected, the tonics just mentioned will 
frequently prove effectual. The constitutional influence of mercury, 
also, " will sometimes cause these tonics to be efficacious when they 
have failed before." (MaccuUoch.) 

The sequela of this form of fever are often both obstinate and 
dangerous in their consequences. The most common of these morbid 
consequences of agues are: — oedema of the feet and legs; enlarge- 
ment and irritation of the liver and spleen ; jaundice ; dropsy ; and 
a general broken down state of the constitution. Authors mention 
other sequela of this disease — such as tympanitis, hemicrania, deaf- 
ness, vertigo, paralysis and epilepsy. The dropsy and jaundice which 
occasionally supervene after very protracted agues, depend, no doubt, 
most commonly on the visceral indurations previously produced by 
the fevers or the miasmata. In nearly all these secondary affections, 
mercury may be regarded as our principal curative means. A gentle 
alterative course will often suffice to remove most of these affections 
— especially the visceral obstructions, and the disorders which depend 

* During each spring of the last three years, T have given immediate reUef to 
a patient suffering from violent periodical headache, (sun pain.) by the following 
recipe : 

JJ. — Sulph. morphisB, gr. i. 

Sulph. quinae. gr. xij.— Make two pills.— S. Take one in the morning before 
the pain appears. 

No other remedy had any good effect, nor the successful recipe in smaller doses 
than those mentioned. 

A mercurial cathartic was first given. 



INTERMITTING FEVER. 127 

on them. Four grains of blue mass, with two of pulv. ipecacuanha, 
ought to be taken every night on going to bed, and a dose of saks 
taken every fourth or lifth day. Wlien the disease is obstinate, and 
does not show a disposition to yield to this moderate mercurial influ- 
ence, two or even three pills may be taken daily, until the gums 
begin to exhibit marks of its influence on the system, when they 
sliould be discontinued, and resumed occasionally, so as to keep up 
a very moderate degree of the mercurial action. Some mild bitter 
infusion may be taken in moderate doses twice or thrice daily, during 
the use of the mercury. 

I have already mentioned the mvriate o{ ammonia, as a valuable 
remedy for the removal of visceral indurations. The formula which 
I have employed with great success in cases of this kind, is as fol- 
lows : 

R. — Muriat. ammonia;, ges. 
Pulv. extract, glycyrrh. |j. 
Tart, antimonii, gr, i. 

Aq. fontanae, §viij. — M. ft. S. Take a tablespoonful every four hours dur- 
ing the day. 

Perhaps the most eflectual remedy we possess for the removal of 
enlargement and induration of the spleen, arising from miasmata or 
intermitting fever, is iodine. I have employed it hi one case, of long 
standing, with decided advantage, after mercury, the muriate of am- 
monia, antimony, &c. had been unsuccessfully used. From eight to 
ten drops of the tincture of iodine should be given three times daily, 
and a mild unirritating and digestible diet enjoined. We may also 
use the iodine in the form of frictions over the left hypochondrium ;* 
but I apprehend the internal use of it will in general prove most 
effectual. 

Tartar emetic, in very small but frequent doses, forms, also, a very 
useful medicine in cases of this kind — more especially for the remo- 
val of that dry and icterode state of the skin, with osdema of the feet, 
which is so common a consequence of protracted agues. The best 
mode, perhaps, of administering this article in these affections, is to 
dissolve it in a large quantity of water, or some mild and pleasant 
ptisan. I have generally directed one grain of tartar emetic to be 
dis.solved in about three pints of water, and to be used freely as com- 
mon drink. By continuing this drink, so as to consume at least a 
quart in twenty-four hours, for eight or ten days, the skin generally 
becomes clear ; the bowels regular ; the cutaneous transpiration natu- 
ral ; and the enlarged spleen, or liver, manifestly diminished in size 
and hardness. 

Relapses are very apt to occur after the paroxysms have been ar- 
rested. The circumstances which seem most capable of causing a 

* K. — ^Hydriodat. potassae, ^ij. 
Axungia;, ^jss. 

Liq. potas. caust. gtt. v. — M. Rub in, the size of a nutmeg of tliis oint- 
ment three times daily. 



128 REMITTING FEVER. 

relapse, are : exposure to cold and damp air ; errors in diet and drink; 
the depressing passions, and renewed or contmned exposure to the 
influence oi koino-miasmnta. All these cases ought, therclore, lo De 
carefully avoided after the disease has been arrested, particularly 
where previous relapses have already occurred in the same case it 
is especially important to avoid every thing which is calculated to 
derange the digestive organs. But nothing, I conceive, is better cal- 
culated to obvfate relapses, than a delay in prescribing febrifuge re- 
medies, mitil the apyrexia is complete, and all signs of a general or 
local inflammatorv condition are removed, and the disease has run on 
at least over the seventh paroxysm in quotidians, and the lourth in 
tertians. When an ague assumes a chronic character, none of the 
usual febrifuge tonics will do more than to cause a temporary sus- 
pension of the paroxysms. In cases of this kind a gentle salivation 
will usually do more good than any other mode of management we 
can adopt. Even if the mercurial influence should not put a perma- 
nent stop to the progress of the disease, it will be apt at least to ren- 
der the system more susceptible to the remedial operation of the bark 
and arsenic, and thus contribute materially to the ultimate removal 
of the disease. 



CHAPTER VI. 

REMITTING FEVER. 



Bilious Fever ; Sahurral Fever. — Febris Pituitosa ; Febris Gas- 
trica ; Febris Intestinalis ; Febris Mesenterica. 

Between the simple autumnal remittent and intermittent fevers 
there exists no essential or radical difference. They are prodnced by 
the same cause ; and differ from each other only in the grade of vio- 
lence and duration of the paroxysm. As remittents, however, as- 
sume a peculiar character, in relation both to their general pheno- 
mena and their course, and demand a treatment correspondingly 
modifled, they are properly made a subject of distinct consideration, 
although some writers, following a different course, treat of them under 
the same general head. 

Symptoms. — Tha symptoms which occur in the forrriing stage of 
remittents, do not differ from those which usher in the intermittent 
paroxysm. Languor, drowsiness, a sense of anxiety, aching pains in 
the back, head and extremities, are the prominent symptoms of its 
initial stage. Slight chills are, however, often among the very first 
manifestations of indisposition — at first they alternate with flushes of 
heat, which latter gradually increase in duration until they predomi- 
nate wholly, and the febrile reaction is fully developed. When the 



REMITTING FEVER. 129 

fever is once completely established, the pains in the head, back, and 
lower extremities, become greatly aggravated. These pains, espe- 
cially those seated in the back and legs, are sometimes so severe as 
to resemble in violence those which occur in acute rheumatism. The 
eyes soon acquire an icterode or yellowish tinge ; the tongue becomes 
covered with a brownish fur; nausea, and occasionally bilious vomit- 
ing occur ; a sense of fullness and weight or tension is felt in the right 
hypochondriura, and epigastric regions ; respiration is more or less 
oppressed and anxious ; the urine is scanty and deeply tinged with 
bile ; the pulse is full, frequent, but seldom very hard or tense, and 
the skin is generally dry and hot. These symptoms continue until 
the succeeding morning, when a gentle perspiration appears on the 
superior portions of the body and sometimes over the whole surface. 
The febrile excitement now abates, frequently, very considerably; but 
not so as to amount to a state of apyrexia— the skin still remaining 
preternaturally warm, and the pulse irritated. This remission con- 
tinues but a short time — not more, commonly, than from one to (wo 
hours. The febrile excitement rises again with more or less celerity, 
until it acquires its former violence, or, perhaps, exceeds it ; which, 
after a certain period, again abates, and gives place to another remis- 
sion. In this way the fever proceeds, undergoing regular revolutions 
of exacerbations and remissions, until it either finally terminates in a 
perfect crisis and convalescence, or assumes a more uniform or con- 
tinued course. This description answers for the simple and usual 
form of the disease, as it occurs in the autumnal months of the tem- 
perate latitudes ; or, for the milder remittents of the warmer climates. 
There is, however, no form of fever which is subject to so great a 
diversity, in relation to its grade of violence, as the present one. In 
the intertropical regions, it usually assumes the most fatal and vio- 
lent character; and at almost every place where it is endemical, it is 
attended with circumstances which give it a somewhat peculiar cha- 
racter. It is, indeed, impossible to give any description of this disease 
which can have more than a very general application. We must 
content ourselves with a delineation of the prominent and character- 
istic outlines of its physiognomy, (if I may be allowed the expression,) 
and with a detail of those phenomena and circumstances which may 
be deemed essential, and which have a particular bearing upon its 
remediate management. 

The ordinary mild remittents of this climate generally assume the 
double tertian or quotidian type ; but the former type is by far the 
most common ; for, although the exacerbations occur once every day, 
yet we almost always find a very manifest aggravation of all the 
symptoms on the odd or alternate days. The exacerbations of a 
remittent of the quotidian type generally occur several hours earlier 
than those of the double tertian type — the former happening usually 
about nine or ten o'clock, and the latter not till towards noon, or an 
hour or two later. 

The remissions which so generally occur in the violence of the 
symptoms of this form of miasmal disease, are not, however, always 
so considerable as to be readily perceived, either by the patient or the 
VOL. I. — 9 



130 REMITTING FEVER. 

physician ; and. in some instances of an aggravated character, they 
may be, for a time, aJtogether inconspicuous or absent. Jt must be 
observed, moreover, that they do not invariably occur m the mornmg 
or forenoon ; on the contrary, instances are met with where the re- 
missions take place in the evening or at some period during the night. 

Remittents, although mild and regular in their commencement, are 
apt to assume an aggravated and dangerous character, if they con- 
tinue unchecked beyond the ninth day, or second week. When this 
happens, the tongue becomes more and more loaded with a brown 
fur, and dry along the middle ; delirium occurs more frequently and 
strongly; the skin acquires a deeper tinge of yellow, and a greater 
intensity of heat during the exacerbation ; debility becomes more and 
more conspicuous, and the bowels distended with flatus, and tender to 
external pressure ; and, finally, in many cases, watery and offensive 
discharge from the bowels, retention of urine, continued vigilance, 
restlessness, and almost constant delirium. 

In the paludal districts of hot climates, remittents rarely occur in 
the mild and simple form which they are wont to assume in the tem- 
perate latitudes. They generally acquire a highly aggravated and 
dangerous character; and under circumstances particularly favourable 
to their occurrence, they are apt to assume a liigh degree of malignity 
from their very commencement. Remittents of this violent grade 
generally make their attack suddenly, and with great impetuosity. 
The cold stage is short, and not often very severe. The febrile 
heat soon predominates and rises rapidly to a state of great intensity 
— and is attended with tormenting thirst, violent headache, excruciat- 
ing pains in the loins and the inferior extremities, great anxiety of 
feeling and difficulty of breathing, with nausea, and a distressing 
sense of weight and fullness in the stomach. These symptoms con- 
tinue for about twenty-four hours, when a remission, always very 
considerable, and frequently amounting almost to a perfect intermis- 
sion, takes place. This calm, however, is but transient. A second 
paroxysm soon ensues, more violent and alarming than the first. The 
eyes now become yellow, watery and red; the oppression and anxiety 
in the epigastrium are extremely distressing, and a deadly sickness, with 
constant vomiting, or retching, torments the patient. After the lapse 
of some time, these violent symptoms again abate, and a clammy 
perspiration appears on the surface of the body. During the first 
two paroxysms, the bowels are, generally, torpid. In this way, the 
paroxysms continue to recur, until either a salutary crisis or death 
takes place, one or the other of which not unfrequently happens in 
the third paroxysm. If the disease runs on beyond the fifth or sixth 
paroxysm, very great prostration ensues ; the remissions become less 
distinct; delirium almost constantly attends ; and the skin acquires 
either that peculiar stinging heat called calor mordax, or becomes 
cool and cadaverous to the touch. The pulse, in cases of this kind, 
frequently differs but little from its natural state ; more commonly, 
however, it becomes quick, irregular and frequent. In this aggravated 
and protracted state of the disease, various other symptoms usually 
occur, in addition to those already mentioned, indicative of the fatal 



REMITTING FEVER. 131 

malignity of the malady. The lips become swollen, and of a livid or 
purple hue ; the tongue dark, brown, or black — fetid and clammy ; 
the eyes red and watery, or quite dry; the urine dark brown, ofl'ensive, 
or entirely suppressed ; the alvine discharges reddish and watery, or 
black, bloody or colliquative, attended generally with a tympanitic 
state of the abdomen ; and petechia and hemorrhages occasionally 
occur in the last stage of the disease. 

In general, the violence of the disease will be in proportion to the 
suddenness and vehemence of the incursion. When the attack ap- 
proaches gradually, with the ordinary premonitory symptoms men- 
tioned above, the disease usually runs its course slowly. When, on 
the contrary, the invasion is sudden and violent, we may expect the 
disease to be rapid and violent in its progress. The Jirst paroxysm 
only is usually ushered in by a very distinct cold stage — the suc- 
ceeding exacerbations being rarely preceded by a sense of chilliness. 

Between the mildest variety of the disease, and the rapid, vehe- 
ment and fatal variety just described, this form of fever appears 
under the greatest diversity of grades and general character. Re- 
mitting, like all other forms of general fever, is liable to become com- 
plicated, either at an early or late period of its course, with local 
inflammations ; and these secondary local affections constitute the 
chief and most important cause of those remarkable diversities which 
are known to occur in this disease, in different localities, or at the 
same place in different seasons. From some inexplicable circum- 
stance, connected, apparently, with the peculiar concentration or 
character of the miasmata, we find that, in certain localities and 
seasons, the disease manifests a peculiar tendency to fall, with espe- 
cial violence, on some one organ or structure, as the brain, the liver, 
the alimentary canal, or the blood-vessels, and to assume, in conse- 
quence, a peculiar character in relation to its general phenomena and 
degree of fatality. 

In general, however, two important organs — the liver and the 
alimentary canal, are the parts most apt to become prominently 
affected in fevers of this kind. In relation to these affections, two 
distinct modifications of the disease occur; one, in which the \)\\q- 
nomena. o( gastro-e7iteritic disorder are especially prominent; and 
another modification, in which predominant hepatic derangement 
impresses its peculiar stamp or character on the disease. To the 
former, the term gastric, and to the latter that of hepatic, might, not 
unaptly, be applied. 

The remittents of the former variety, namely, gastric remittents, 
are characterized by the following phenomena, viz. : redundancy of 
vitiated bile in the stomach and bowels; a bitter taste; a thick 
yellowish layer of mucus on the tongue, becoming dry, cracked, and 
of a dark brown or black colour in the progress of the disease ; total 
loss of appetite, and sometimes extreme disgust for every kind of 
food ; a turbid, yellowish, or jumentose urine ; great weight and 
anxiety in the prsecordia ; bowels tender on external pressure, and 
distended with flatus; great pain in the loins and knees; intense 
pain in the forehead ; very distinct remissions ; a red or fiery edge 



132 REMITTING FEVER. 

and tip of the tongue: or after the brown and black crust scales off, 
a smooth, shining, and red surface of the tongue; watery and red- 
dish stools resembling the washings of flesh; retention of the urme; 
difficulty of swallowing liquids in the advanced stage ; great cravmg 
for cool and acidulated drinks, &c. . 

Those remittents which manifest predominant hepatic disorder, 
that is, hepatic remittents, are characterized by intense febrile heat; 
violent pains in the head, and early delirium ; fullness and tension in 
the right hypochondrium, with pain and pulsation in the epigastrium 
and right hypochondrium ; a clean tongue, at first ; excessive irri- 
tability of the stomach; frequent and forcible vomiting, without the 
ejection of any bile, the matter brought vp consisting of a glairy 
fluid, mixed with the drinks that may have been received into the 
stomach ; great torpor of the bowels ; a very yellow tinge of the 
skin, and tunica albuginea ; and towards the determination of the 
disease, a copious discharge from the bowels of a dark or pitch-like 
matter. In this variety of the disease, the liver is manifestly inac- 
tive, and in a state of great sanguineous congestion. That this is the 
case, may be inferred from the absence of bile in the ejections from 
the stomach ; the clean tongue ; the sense of weight, fullness and pul- 
sation in the right hypochondrium; the great torpor of the bowels; 
the intensely yellow colour of the skin ; and the excessive and con- 
tinued retching and vomiting. This latter symptom, namely, 
extreme irritability of the stomach, may be regarded as a strong 
manifestation of sa7iguineous engorgement and functional inac- 
tivity of the liver. We find this pathological fact exemplified in 
cholera, particularly in cholera infantum, in which disease there is 
seldom any bile whatever discharged during its early period ; and 
the appearance of this secretion in the discharges may be hailed as a 
very favourable occurrence. Towards the conclusion of this variety 
of remittent fever, the liver frequently recovers its action and re- 
lieves itself by pouring a large quantity of black bile, or perhaps 
blood, into the bowels, as is manifested by the copious dark-coloured 
or tar-like alvine discharges which usually occur in such cases. — 
These large and very peculiar discharges may, indeed, be regarded 
as the favourable crises of such fevers ; for convalescence generally 
soon follows their appearance ; and except the disease be arrested by 
remedial treatment in the early period of its course, there are but 
few recoveries in which such discharges do not occur. Dr. Cart- 
wright describes an epidemic fever, which prevailed in Monroe 
county, Mississippi, in the autumn of 1822, which was strikingly 
marked by the characteristic phenomena of this variety of fever.— 
« The disease," he says, « was generally ushered in by a distinct 
chill, which was speedily followed by intense heat, thirst and head- 
ache, and very severe pains in the loins. The anxiety and difficulty 
of breathing, the deadly sickness, sense of weight, heaviness, and 
pain in the stomach, increased as the fever approached its acme, 
until the suffering became intolerable. The exacerbations generally 
occurred in the evening, and a considerable remission, amounting in 
some cases to a perfect intermission, took place on the ensuing morn- 



KEMITTING FEVER. 133 

ing. On the evening of the second day a sudden and unexpected 
paroxysm, more violent than the first one, came on, which was 
attended with a most horrid sensation of pain and oppression of the 
stomach, accompanied with deadly sickness and continued vomiting, 
but luith the ejection of very little fluid of any kind. The bowels, 
during the first and second paroxysms, were always in a state of 
obstinate constipation. About noon of the third day the third pa- 
roxysm generally came on. During this paroxysm the skin usually 
felt rather cooler than natural, and the pulse was commonly remark- 
ably slow. By placing the hand on the abdomen, a pulsation was 
felt equal to that which the heart produces in the thorax, and syn- 
chronous with the pulsations of that organ." During the first two 
paroxysms the tongue was but little furred ; but in the third it as- 
sumed a much worse appearance, having a dark red line running 
from its extremity over its dorsum, which soon changed to a black 
colour. The skin began to acquire a yellow colour during the third 
paroxysm. The paroxysms continued to recur until the fifth, seventh, 
or ninth day, when either death took place, or " enormous dark-co- 
loured evacuations from the bowels occurred, and the patient com- 
menced to convalesce."* 

Although the symptoms just mentioned clearly indicate very promi- 
nent disorder of the liver, it is equally evident, that in these cases, the 
mucous membrane of the stomach and bowels is always, perhaps, in 
a state of considerable irritation, and probably often of inflammation. 
Nevertheless, it can scarcely be doubted that the peculiar phenomena 
of this variety of the disease, and which distinguish it from other 
modifications of remitting fever, depend mainly on certain morbid 
conditions of the biliary organs, and which do not occur to the same 
extent in other varieties of the disease. More or less derangement 
of the biliary system appears, indeed, to be a universal attendant on 
remitting fever. The tendency of miasmata to act upon and disorder 
the liver, has already been particularly mentioned ; and it may be 
presumed, from this circumstance, independent of the phenomena of 
the disease, that prominent functional disorder of the liver constitutes 
one of the most constant local affections of remitting fever. 

Before I leave this part of the present subject, it may be useful to 
advert again to the former or ^a^/nc modifications of this disease, 
and to direct the attention of the reader more particularly to the great 
tendency there exists in remittents, when they are prolonged in 
their course, to the occurrence of a high grade of irritation or sub- 
acute inflammation of the mucous membrane of the intestinal canal. 
In most cases of protracted remittents, even of the mildest kinds, the 
abdomen becomes somewhat tympanitic, and tender to external pres- 
sure ; and the character of the stools, which are often found to resem- 
ble the washings of flesh, are a further evidence of such a condition 
of the bowels. In a practical point of view, it is of the utmost con- 
sequence to be aware of this circumstance: for in many instances 
this secondary inflammation is excited by the too frequent employ- 

* Medical Recorder, vol. vi. 



134 REMITTING FEVER. 

ment of irritating purgatives, and the disease greatly aggravated and 
protracted by such a course of treatment. 

In locahties where miasmata are copiously generated, or possess 
great virulency, remitting fever sometimes comes on under symptoms 
of cerebral disorder, simulating apoplexy or mental derangement. — 
In Italy, and the intertropical countries, the disease not unfrequently 
makes its attack under one or the other of these cerebral affections. 
Sudden and furious mania is sometimes among the first manifesta- 
tions of the disease ; and many patients sink at once into a state of 
insensibility and apoplectic oppression, from the vehement action of 
the miasmata on the brain. The brain, however, is not so apt to 
suffer inflammation in this form of fever, as in those which are the 
product of idio-miasmata, contagion, or atmospheric vicissitudes. — 
This, at least, may be affirmed of the ordinary remittents of the mid- 
dle latitudes ; and it is probably generally correct in reference to all 
malarious fevers. Nevertheless, when the mucous membrane of the 
alimentary canal becomes inflamed, the brain usually manifests 
strong sympathetic irritation, by more or less violent delirium of 
nearly uninterrupted continuance. It is perhaps on this account, 
namely, the comparative infrequency of cerebral inflammation in 
remittents, that we do not so often observe that sudden and remark- 
able collapse of the vital energies in this disease, as in the fevers 
produced by other causes. 

The ordinary remittents of the temperate latitudes often terminate 
in intermitting fever before the final disappearance of the disease ; and 
it is not uncommon for the milder varieties of the disease to assume the 
intermittent form at an early period of their course. This conversion 
of form appears to be particularly favoured by blood-letting practised 
during the first few days of the fever. Remittents, also, frequently 
terminate in other affections, such as neuralgia; chorea; paralysis; 
mental weakness ; organic disorder of the liver and spleen ; dropsy; 
pain and swelling of the large joints, &c. 

Causes.— Aiier: what has been already said under the heads of 
koino-miasmata and intermitting fever, m relation to this subject, 
it will be sufficient to observe, that besides koino-miasmata, which 
are unquestionably the sole epidemic source of this form of fever, 
there are a variety of other causes capable of producing this malady. 
Worms and other irritating substances lodged in the bowels, may give 
rise to a regularly remitting form of fever. The disease known under 
the term of "infantile remittent," appears to arise from intestinal 
irritation. In the remitting fevers produced by causes of this kind, 
however, the biliary organs are much less apt to become implicated 
than they almost invariably are in the miasmatic remittents. What- 
ever may be the remote cause of remitting fever, however, it seems 
very evident that the principal morbid irritation is always located in 
the abdominal organs, and more especially in the liver and mucous 
membrane of the alimentary canal. So unequivocal and universal is 
this gastric disorder or irritation, that some eminent physicians have 
in consequence of it, designated the disease by the name of "^astric 
fever:' (Richter.) ^ 



REMITTING FEVER. 135 

TnxJeed, this term appears to me preferable to that of remittent, 
which has no reference to the pathological condition of the system, and 
might, with equal propriety, be applied to hectic fever, which, though 
very distinct from remitting fever, has remissions and exacerbations 
almost as conspicuous and regular as that disease. 

Treatment. — The principal indications to be fulfilled in the treat- 
ment of remitting fever are: 1, to moderate the febrile reaction of the 
arterial system; 2, to remove out of the alimentary canal the vitiated 
and irritating secretions which may be lodged in it ; and 3, to obviate 
gastro-intestinal irritation, and restore the healthy functions of the 
liver, and alimentary tube. I shall speak in the first place of the 
treatment proper in the milder or gastric variety of Ihe disease. 

With regard to the first of these indications, very discrepant senti- 
ments have been expressed as to the particular means best calculated 
for its fulfilment. Some recommend a prompt and free employment 
of the lancet as decidedly beneficial in the treatment of remittents, 
whilst others admit its occa^zor/^/ utility, and others, again, represent 
it as frequently injurious, and rarely beneficial. In the ordinary 
autumnal intermittents of this climate, blood-letting, I am well satis- 
fied, may be often, very properly, entirely omitted. The pulse, in 
the milder cases of this disease, particularly where the intestinal canal 
is loaded with bilious and other saburral matter, is not often suffi- 
ciently hard and tense to warrant copious or repeated abstractions 
of blood. In such cases, when unaccompanied by symptoms of strong 
local congestions or visceral inflammation, I have not found it necessary 
to draw blood. There can be no doubt, however, that in particular 
localities, and under peculiar circumstances of atmospheric constitution 
and vicissitudes, remitting fever may sometimes assume a character 
which demands the free use of the lancet. To condemn the use of 
the lancet universally would be as erroneous as to enjoin its invaria- 
ble employment. Bleeding cannot be employed or withheld, merely 
on the ground that we are prescribing for a particular disease. In 
all maladies, the state of the pulse must be our main guide, in rela- 
tion to the use of the lancet. When the pulse is either hard or tense, 
whether it be full or contracted, blood may be safely, advantageously 
drawn, whatever may be the name, or the general character of the 
disease. 

In cases that are attended with violent pains in the head — a full, 
vigorous, and hard pulse, with a very hot and dry skin, bleeding, is, 
unquestionably, decidedly indicated, and ought not to be neglected. 
Having moderated the momentum of the circulation by venesection, 
where this measure is indicated, the attention should next be directed 
to the alimentary canal. Considerable discrepancy of opinion has 
been expressed, in relation to the employment oi emetics m. the treat- 
ment of remitting fever. In the ordinary autumnal remittents of the 
temperate climates, gentle emetics will often afford some advantage; 
but their usefulness is, probably, much too highly estimated by the 
majority of those who are in the habit of employing them in this 
disease. I have of late years but rarely resorted to them in this form 
of fever, and I am inclined to think, that they may be generally well 



136 REMITTING FEVER. 

dispensed with, without losing any peculiar remedial advantages. 
There exists a decided tendency to gastro-intestinal irritation in every 
modification of this disease ; and, although the operation of an enietic 
may procure temporary benefit, yet some risk will be incurred of its 
exciting a degree of permanent irritation, which will subsequently 
exercise a most pernicious influence upon the phenomena and pro- 
gress of the disease. In the year 1822, I attended a considerable 
number of patients labouring under the milder form of remitting fever. 
During the early part of the season, I prescribed an emetic in the 
majority of cases that came under my care. In many of these cases, 
a great degree of gastric irritability continued to prevail during the 
first period of the malady, and in the advanced stages, much tender- 
ness and tympanitic tumefaction of the abdomen supervened. The 
disease, in these instances, was wont to run a tedious course — the 
abdomen became sore to pressure, and the alvine discharges often 
became watery, reddish, and painful — in short, unequivocal manifes- 
tations of high irritations or phlogosis of the intestinal mucous mem- 
brane often supervened. Towards the middle period of the season I 
left off" employing emetics entirely; and with the exception of one or 
two brisk cathartics, in the commencement, confined myself to the use 
of the milder laxatives, to keep up the requisite discharges from the 
bowels. From this time on, I met with but few cases in which the 
former unfavourable symptoms occurred. It must be confessed, how- 
ever, that there are very respectable authorities to be adduced in 
favour of the use of emetics, not only in the mild, but even in the 
more rapid and violent varieties of this form of fever. Whatever 
doubts may be entertained in relation to the usefulness of emetics in 
the ordinary forms of remitting fever, the weight of good testimony is 
decidedly against their employment in those violent grades of the dis- 
ease which occur in hot climates, and in which there exists, generally, 
the utmost degree of gastric irritability. That emetics may sometimes 
be administered without detriment, and even with benefit in these 
vehement and dangerous varieties of the disease, may be admitted; 
but it is most obvious, that no small degree of danger must be incurred 
from the impressions of such a remedy upon the delicate and already 
irritated or highly irritable mucous membrane of the stomach. The 
foregoing observations apply with still greater propriety to the em- 
ployment of what are termed emeto- cathartics. Chisholm speaks 
favourably of their employment ; but there have been, comparatively, 
few practitioners who appear to have found them beneficial, I do not 
doubt that, in the milder cases, the conjoined operation of an emetic 
and a purge, will occasionally make a favourable impression on the 
disease ; but I am equally satisfied, that much injury may result from 
the irritation which they are calculated to produce. In relation to this 
subject. Dr. Heustis, of Alabama, whose opinions are entitled to much 
respect, makes the following observations. "As far as my observa- 
tion extends, I think I am warranted in saying that tartar emetic can 
never be prudently exhibited in the high and malignant grades of 
biUous fever. I am confirmed in this opinion from having seen and 
known so many instances of alarming, and sometimes fatal prostration 



REMITTING FEVER. 137 

produced by its exhibition ; I have known a person in a high fever, 
with a strong and full pulse, and generally increased temperature of 
the body, in less than two hours after taking this poisonous medicine, 
to be affected with a death-like coldness ; the pulse at the wrist no 
longer perceptible, the eye inanimate, the lips, cheeks and extremities 
exhibiting the lividity of death, a cold and copious sweat exuding from 
the general surface of the body, and every symptom of approaching 
dissolution. Frequent occurrences of this nature have, for the last 
two years, almost entirely banished the use of tartar emetic from my 
practice ; nor do I ever exhibit it except in the intermitting form of 
fever, or mild cases of remittents, and even in these instances expe- 
rience has proved that its exhibition is unsafe, except in the recess or 
remission of the fever."* 

Whatever may be thought of the propriety of administering 
emetics or emeto-cathai'tics in this disease, almost universal expe- 
rience speaks decidedly in favour of the employment of purgatives, 
not only in the beginning, but at proper intervals tin'oughout the 
whole course of the disease. In all instances where the irritability 
of the stomach does not forbid the administration of a purge, the 
bowels should be early and thoroughly evacuated by a suitable 
purgative. A combination of calomel and jalap, in the proportion 
of ten grains of each, will, in general, suffice to procure adequate 
evacuations. Having emptied the bowels well, by a brisk cathartic 
in the onset of the disease, recourse must next be had to such reme- 
dies as are calculated to restore the healthy functions of the liver, 
alimentary canal, and skin, and to moderate the general febrile 
excitement, and obviate or remove the local congestions or inflam- 
mations that may supervene. 

To correct the morbid condition of the liver, skin, and alimentary 
canal, constitutes the chief part of the treatment of this malady. 
For this purpose, the following combination will often answer ex- 
tremely well : 

R. — Pulv. nitrat. potassae 3j. 
Pvilv. ipecac. 
Calomel aa gr. xii. — ]M. ft. Divide into six equal parts. 

One of these powders is to be taken every two or three hours. 
The substitution of the ipecacuanha for the usual ingredient, tartar 
emetic, will obviate the tendency of this mixture to irritate the 
bowels, and to cause frequent and griping watery stools — which 
rarely fail to aggravate the violence of the disease. Calomel is a 
most important remedy in this form of fever. Its power of altering 
the morbid condition of the liver, and of the whole capillary system, 
together with its gentle aperient effects on the bowels, renders it 
peculiarly calculated to do good in this disease. To obtain these 
important advantages, the calomel should be early and regularly 
administered, and continued until slight manifestations of its specific 
influence on the system may be noticed in the gums. When this 
occurs, its use must be suspended. For more than fifteen years I 

* The Amer. Journ. of the Med. Sciences, vol. ii. p. 40. 



Ii39 REMITTING FEVEK. 

have employed this remedy in nearly every case of remitting fever 
which has come under my management, where I have been called 
to the patient during the first two or three days of the disease. In 
a great majority of these cases, I found all the symptoms of the dis- 
ease to abate, often very considerably, as soon as the mercurial 
influence became conspicuous ; and in many instances a speedy 
convalescence ensued. Although a very gentle mercurial impres- 
sion is generally decidedly benefical in this malady, yet strong 
mercurialization, or ptyalism, appears to be generally detrimental— 
at least in the ordinary remittents of this climate. It is to be ob- 
served, moreover, that in the advanced periods of the disease, the 
constitutional operation of mercury will be much more apt to prove 
' injurious than beneficial. In general the salutary influence of mer- 
cury is restricted to the first five or six days of the disease ; and the 
earlier its general operation can be procured, the more certainly will 
it prove advantageous. 

When the above combination of calomel, nitre, and ipecacuanha 
excites active purging, as has sometimes been the case, we may not 
only lose the specific influence of the mercurial, bat there is danger 
of superinducing inordinate irritation in the mucous membrane of 
the intestinal tube. Whenever frequent painful and watery stools 
follow the exhibition of the above combination, the nitre ought to be 
left out, and ipecacuanha or small doses of Dover's powders added 
to the calomel. Throughout the whole course of this disease, a 
gentle and regular action of the bowels ought to be carefully pro- 
moted by mild laxatives ; but, excepting in the very commencement, 
strong and irritating cathartics, especially when frequently adminis- 
tered, are often prejudicial. There is no class of remedies which is 
more indispensable in the treatment of remitting fevers than laxa- 
tives ; and yet there are no medicinal agents which are so frequently 
abused, or improperly employed in this disease, as this very class 
of evacuants. Violent and irritating cathartics, when repeatedly 
administered in this form of fever, seldom fail to induce a state of 
irritation in the mucous membrane of the bowels, from which a train 
of distressing and dangerous consequences arise in the advanced 
stages of the malady, which are often of more serious import than 
the original disease itself. The thin, watery, muddy, reddish and 
fetid stools— the tympanitic and tender state of the abdomen — and 
the cerebral irritation, which frequently occur in the latter period of 
the disease, are very often the results of the frequent use of active 
and irritating cathartics in its treatment. " There is one fault which 
a physician sometimes commits in the treatment of bilious remittent 
fevers, and that, too, for the most part, when he thinks he is doing 
right. I allude to the too long continuation of purgative medicines. 
He is apt to think that the impurities have been long fixed in the 
bowels, and, in order to cleanse his patient thoroughly, and to leave 
nothing noxious behind, he persists in the use of purgatives. What 
is worse, every appearance of these cases would seem to justify his 
suspicion of the existence of fixed impurities of long standino- in the 
bowels, and confirms him in his design of at once, and for all making 



REMITTING FEVER. 139 

a clean house. The longer he continues to give his purgatives, the 
fouler does the tongue become, and the more distressed the stomach; 
the symptoms, in short, of intestinal impurities become more and 
more conspicuous, whilst he continues to dilute and to evacuate, 
without reflecting or knowing that he is himself the cause of all the 
noxious matter in the intestines, by constantly irritating them with 
his purgatives, and keeping up an afflux of fluids to the internal or 
villous coat. The most healthy individual will get a foul tongue and 
lose his appetite, if he take neutral purgative salts for several days 
in succession."* 

Although frequent and harsh purgation is generally decidedly 
detrimental in the treatment of this form of fever, yet the total pro- 
scripiinn of laxatives from the list of remediate agents suitable for 
its cure, is no less calculated to favour injurious consequences. 
There is always an abundance of vitiated bile and other morbid 
secretions poured into the bowels in this disease ; and the generation 
of acrid and irritating materials by putrefactive and fermentative 
decomposition in the bowels, soon adds greatly to these sources of 
intestinal irritation, if the bowels be not, from time to time, gently 
evacuated by laxatives. Mere purgative enemata and bland diluents 
are wholly inadequate to remove these permanent irritants from the 
bowels, or blunt their activity. The irritation which such intestinal 
impurities create, must be vastly more intense and protracted than 
the trifling and transient irritation of a laxative administered for their 
expulsion. In the commencement of the fever we may employ one 
or two active purges, viz: 

R. — P. Jalap. Calomel aa gr. xii. 

Or, 

R. — Extract, colocynth. comp. gr. xii. 

Calomel gr. x. — M. Divide into four pills, to be taken at one dose. 

Or, 

R. — Calomel . . . . gr. x. To be followed with one ounce of sulphate of soda, 
in three hours after the calomel is taken. 

After the first, or, at most, the second thorough purgation, the 
mildest laxatives, assisted with acidulated diluents, ought alone to be 
employed for evacuating the bowels ; such as the Seidlitz powders; 
small portions of Epsom salts, preceded by a iew grains of calomel ; 
castor oil, with a few drops of laudanum ; a mixture formed of mag- 
nesia, castor oil, and lemon syrup, constitutes an elegant, pleasant, 
and gentle laxative, which I have often used with very excellent 
effects. It is made by mixing very intimately in a mortar an ounce 
of the oil with a drachm of carbonate of magnesia, and then adding 
and mixing with it about an ounce of any of the usual syrups. Of 
this a large tablespoonful is to be taken every hour, until the bowels 
are moved. From two to three evacuations ought to be procured 
every twenty-four hours during the whole course of the disease. 

* Medical and Surgical Observations, page 120. 



140 REMITTING FEVER. 

Much of the treatment of fevers of this kind depends on the judi- 
cious management of purgatives. Circumstances may mdeed occur, 
which will render the employment of an active purge peculiarly 
beneficial even in the latter periods of the disease. This is particu- 
larly apt to occur in those violent cases in which the liver at last 
pours out large quantities of black bile, and which, if not speedily 
removed, may cause a prostration or oppression of the system by 
exciting a state of general nervous irritation. Along with the reme- 
dies already mentioned, some advantage may be obtained from the 
usual antiphlogistic diaphoretics— such as the effervescing saline 
mixture, the spiritus mindereri, and the free use of bland acidulated 
drinks. The following mixture will be found a decidedly useful 
remedy in cases attended with much restlessness, anxiety, and a hot 
and dry skin, where there is no particular determination to, or ex- 
citement of the brain, and the febrile reaction is not very violent.* 
K. — Liquor Ammonise acetat. §vij. 

Spir. nit. dulc. gj. 

Tinct. opii. acetat. gtt. 30. — M. ft. Of this a tablespoonful may be taken 
every three hours. 

Nitre, with small portions of tart, antimony, dissolved in a bland 
mucilaginous fluid, will, in general, assist considerably in reducing 
the febrile heat, and promoting diaphoresis. We may also employ 
a solution of the muriate of ammonia, with much advantage, 
according to the formula given at page 127 of this volume. Indeed, 
this article administered in the manner directed by this formula, 
appears to me better calculated to do good in bilious remittents than 
nitre. It should be particularly observed, however, that both these 
remedies, more especially nitre, cannot be properly employed in 
cases attended with much gastric irritability, or gastro-enteric irri- 
tation. 

When the skin is very hot and dry, during the exacerbations, the 
sufferings of the patient may be much alleviated by sponging the 
body with cool water, and suffering it to evaporate by the heat of 
the body. 

The use of mild, cool and acidulated beverages ought to be en- 
joined as an important item in the treatment of this disease. Inde- 
pendent of the effects which drinks of this kind have in blunting the 
acrimony of the fluids lodged in the alimentary canal, they usually 
exert a soothing antiphlogistic influence upon the system, and they 
may do much good, moreover, by supplying the intestinal absorbents 
with a fresh and wholesome fluid, and thereby preventing or lessen- 
ing the absorption of irritating or vitiated matters from the bowels. 
Drinks made with lemon or citric acid and sugar, are, perhaps, the 
best diluents for this purpose. Barley-water, acidulated with lemon 
juice; warm water poured on sliced apples, and afterwards suffered 
to cool— fresh orange juice diluted with cool water, or currant jelly 
mixed with water, are grateful and salutary beverages. 

* Dr. Agnew on the late epidemic, intermittent, and remittent fever at Harris- 
burg. Vide Medical Recorder, vol. vi., p. 147. 



REMITTING FEVER. 141 

When, either from the imprudent employment oi irritating purges, 
or from other causes, the mucous membrane of the intestinal canal 
is brought into a state of high irritation or subacute inflammation, 
the disease generally loses its remittent form, and often assumes a 
low typhoid character, with almost constant delirium, a tender and 
tympanitic state of the abdomen, a dry, dark-brown, or black crust 
on the tongue, with clean red edges ; watery and reddish stools ; 
great prostration; and a very dry and hot skin. Cases of this kind 
frequently nm on for several weeks ; and convalescence is always 
very gradual and tedious. When the fever assumes this aspect, our 
remedial measures must be chiefly directed against the intestinal 
phlogosis. Leeching the abdomen will often afford much benefit ; 
and it ought never to be neglected where leeches can be had. A 
large emollient poultice will assist, very materially, in reducing the 
intestinal affection. 1 am perfectly satisfied that we may, in general, 
derive much more good from applications of this kind than from 
blistering. Fomentations with flannel wrung out of hot water, will 
answer the same purpose ; but this mode of fomenting is more 
troublesome, much more variable in its impressions, than the appli- 
cation of warmth and moisture by means of a poultice, and probably 
not more efllcacious. Internally I have exhibited small doses of 
calomel and opium in such cases with manifest advantage. The 
one-sixth of a grain of the former with a quarter of a grain of the 
latter may be given every two or three hours. The bowels must 
be kept open by laxative enemata, and the patient requested to take 
freely of some bland mucilaginous fluids — such as barley water, very 
thin oat-meal gruel, or gum arable dissolved in water. No other 
articles of food must be allowed, on any account. In such cases, I 
have thought that considerable benefit was derived from epispastics 
on the legs just above the ankles. This measure is particularly useful 
M''hen the extremities are cool, while the skin of the body is hot — a 
circumstance which is not uncommon in instances of this kind. An 
emulsion of balsam copaiva also will frequently procure considerable 
advantage. I have so often seen the most decided benefit derived 
from this article, in protracted cases, attended with great irritation, or 
subacute inflammation of the bowels, that I should consider myself 
as neglecting an important curative means, were I to omit prescrib- 
ing it in diseases of this character. It may be given thus : 

R. — Bals. copaiv. Jss. 
Sacch. albi Jss. 
Pulv. gum arab. 3ij. 
Misce. dein adde, 
Aq. fontance ^ij. — M. ft. Take a spoonful every two hours. 

Although very considerable prostration often occurs in such cases, 
stimulants or tonics are by no means admissible, anterior to the pe- 
riod of convalescence. 

Hitherto I have spoken only of the simple or less violent variety 
of remitting fever — of those remittents which occur in the temperate 
latitudes, and which, though sometimes both violent and rapid in 



142 REMITTING FEVER. 

their progress, do not assume that high and dangerous grade of fe- 
brile action which is so common and so fatal in hot chmates. In the 
higher and mahgnant forms of remitting fever, a treatment somewhat 
different from the one I have just detailed, is requisite. In these ag- 
gravated states of bilious remitting fever, the liver is deeply impJi- 
cated, and the stomach is generally extremely irritable. Here, there- 
fore, we cannot commence as we may in the simpler forms, with 
emetics, or emeto-cathartics, and often not even with a purgative. 
Instead of irritating the stomach by medicines of this kind, our first 
object, often, must be to allay the excessive gastric irritability, in 
order to enable the patient to retain the remedies which his case may 
demand. Among the means which experience has shown best cal- 
culated to effect this purpose, blood-letting holds, perhaps, the first 
rank, where the arterial reaction is vehement. To be beneficial in 
this respect, however, it must be early and copious. I have known 
excessive irritability of the stomach and retching promptly checked, 
in the onset of the disease, by one efficient bleeding. Sinapisms over 
the epigastrium will sometimes aid considerably to moderate the ex- 
cessive gastric irritability, but applications of this kind cannot be gene- 
rally used with propriety until the reaction of the heart and arteries 
has been, in some degree, moderated by venesection. A draught of 
cold water is not only extremely grateful, but, when the skin is hot 
and dry, often very beneficial in restraining excessive vomiting in 
cases of this kind. The saline effervescing draught, artificial mineral 
water, (carbonated water,) the warm bath, lime water and sweet 
milk, spiritus mindereri, have all been recommended and used for 
this purpose. Sinapisms laid on the calves of the legs will sometimes 
speedily diminish the morbid irritability of the stomach, in cases of 
this kind. 

I have just stated that blood-letting is one of the best, if not the 
most effectual means for allaying the extreme irritability of the sto- 
mach which is apt to occur in the violent grades of this disease. 
This observation applies, however, to such cases only as are attended 
with high vascular reaction, for where the vital energies are pros- 
trated, this evacuation is of course inadmissible. Having allayed 
the gastric irritability where it was excessive, our principal reliance 
must be placed in the judicious employment of calomel. The liver, 
in this violent grade of the disease, is generally congested, torpid, or 
otherwise deranged to a very great degree ; and our remedial efforts 
must, therefore, be particularly directed to this viscus. Experience, 
indeed, has fully demonstrated the excellent effects of calomel in this 
affection. There are some practitioners, it is true, of great respecta- 
bility, who do not approve of the free employment of mercury in this 
disease ; but by far the largest proportion of those who have practised 
in warm climates — particularly of the American and British practi- 
tioners—have given their decided testimony in favour of the mercu- 
rial treatment in the higher grades of miasmal fevers. In no country 
in the world, perhaps, is calomel so freely employed in the treatment 
of this malady as in the southern sections of the United States. The 
almost unanimous testimony of our southern physicians (many of 



REMITTING FEVER. 143 

whom are deservedly held in high estimation for their talents and 
medical acquirements), in favour of this practice, will scarcely permit 
us to doubt of its general usefulness. The American practitioner, 
free from the trammels of systems, and the dogmas of the schools, 
pays no further regard to the verba magisiri than is sanctioned by 
his own experience and observations. He inquires, observes and 
reflects for himself, and adopts that mode of treatment which he finds, 
from varied experience, most successful. A practice, which has re- 
ceived the approbation of a numerous portion of the profession, may 
be confidently regarded as founded on individual experience and ob- 
servation, and not adopted on mere authority, and entitled, therefore, 
to full confidence.* 

As it is of the utmost consequence to make an early and decided 
mercurial impression on the system, the calomel ought to be given 
in large and frequent doses. From ten to twenty grains should be 
administered every lour or five hours, until the gums begin to show 
its influence, or imtil the evacuations become conspicuously bilious. 
While we thus endeavour to produce a general mercurial action, and 
especially to restore the regular functions of the biliary organs, the 
bowels should be kept freely moved by additional aperients, if the 
calomel do not produce this effect by itself If the bowels be not 
freely evacuated by the first two doses of calomel, an additional pur- 
gative ought to be administered. For this purpose, an ounce of the 
sulphate of soda, or of magnesia ; or from fifteen to twenty grains of 
the compound extract of colocynth ; or a dose of calomel and jalap, 
will generally answer well. In general, however, very active purges 
will be less beneficial or proper than the milder ones. Indeed, so 
long as the liver remains inactive and engorged, it will rarely be ad- 
visable to repeat even the purgatives I have mentioned. After the 

* From 20 to 60 and even 100 grs. of calomel are frequently given at a dose, 
and in repeated doses, too, by eminent practitioners in the southwestern states, 
during the progress of their bilious fevers. They assert that such doses allay intes- 
tinal irritation, convert fluid into fecal discharges, and rouse and sustain the sink- 
ing energies of the system. I regard Dr. Cartwright, of Natchez, as one of the 
highest authorities in our profession, and would beg to refer every intelligent 
reader to his papers in the Medical Recorder. His views and statements have 
been corroborated by many of the best educated men I have met with from that 
region. They have been still further corroborated by the results of Dr. Annesley's 
experiments upon dogs in India. That gentleman proved that very large doses 
of calomel administered to dogs, would detach the intestinal mucus from the inner 
coat of the stomach and bowels, converting it by chemical action into a grayish 
saponaceous substance, which, admixed with bile, produced consistent fecal dis- 
charges, sometimes greenish, sometimes brown in colour. At the same time the 
remedy contracted the blood-vessels of the mucous membrane and blanched all 
the parts, so as to remove every trace of vascular irritation or inflammation in them. 
We have often had opportunities of witnessing the same result in inflammation 
of the conjunctiva. Insufflation of calomel under the eyelids, will often excite con- 
traction of the distended vessels, and blanch the moist, red and engorged surface, 
relieving at the same time, all the sensations of irritation. — (Mc.) 



144 REMITTING FEVER. 

first efficient mild purge, it will be generally much the best plan to 
keep the bowels open by laxative enemata, and the use of tamarind 
water, or the Seidlitz powders, if these can be had. When the liver 
begins to act, and to pour its dark bile into the bowels, however, 
laxatives of a more active character become indispensable. In cases 
attended with a distressing sense of sickness, accompanied with sore- 
ness in the epigastrium, leeching, succeeded by a large blister over 
this region, will often atford much relief. Experience does not, how- 
ever, offer much in favour of the employment of blisters as a general 
remedy, either in this or the more mild variety of the disease. 

Little or no advantage is to be obtained from the ordinary dia- 
phoretic remedies in the higher grades of the disease. M/re, indeed, 
and the antimonial preparations are wholly out of the question where 
there is much gastric irritability. Where the stomach will bear it, 
James's powder^ in small doses, with calomel, may often be advan- 
tageously employed. The saline effervescing draught, and the spiritus 
mindereri, will sometimes aid in allaying the sickness of the stomach, 
and removing the torpor of the cutaneous exhalents. In all instances, 
perhaps, the enjoyment of cool, acidulated drinks — such as lemonade, 
thin barley water, with a little fresh lemon juice, ought to be freely 
allowed. Tamarind water also is an excellent beverage in cases of 
this kind, on account particularly of its aperient properties. Drinks 
of this kind tend to moderate the intense febrile heat, and they do 
good, moreover, by diluting and obtunding the acrimony of the 
vitiated fluids, which are almost continually generated in the ali- 
mentary canal. 

The propriety of employing tonics during the remissions of the 
disease is a point which has been very variously represented by dif 
ferent writers. Lind, Clark, Balfour, and a host of others contend 
zealously for the vigorous exhibition of bark as soon as a considerable 
remission occurs in the disease. Dr. James Johnson, on the contrary, 
with a number of other late writers on this disease, condemns this 
practice in terms of unqualified reprobation. Dr. Burnet, in his 
Essay on the Bilious Remittents along the Mediterranean, asserts 
that, under "the use of the cinchona, the mortality has been great; 
relapses frequent ; and the supervention of dysentery manifestly 
more frequent." I presume that the cinchona may be injurious, or 
beneficial, according to the period of the disease, or the circumstances 
under which it is administered. Where there are no violent visceral 
congestions — where the liver has resumed its regular action, and 
where, with these favourable circumstances, the remission is complete, 
the bark or the quinine in large doses will often do a great deal of 
good. The authority of many of the most respectable of our southern 
brethren might be cited in confirmation of this remark. There can 
be no question, however, that so long as the liver remains torpid and 
engorged, or where strong local congestion, inflammation, or irrita- 
tion is present, the bark will not only be useless, but, generally, 
decidedly injurious. No matter how slow and soft the pulse may 
be, so long as the abdomen remains tender to pressure, the tongue 
and skin dry, and the alvine discharges free from bile, bark and all 



YELLOW FEVER. 145 

Other tonics are contra-indicated, and cannot be resorted to without 
great risk of irreparable injury. When, on the other hand, th€ oc- 
currence of a remission is attended with a soft and moist skin and 
tongue, signs of bile in the stools, and freedom from abdominal ten- 
derness, the quinine will, in general, prove highly beneficial.* 

The aftusion of cold water has been highly extolled by some, in 
the treatment of this disease. It does not appear, however, that this 
measure is calculated to do any good iu the more violent grades of 
bilious remittents, where strong congestions and derangements of the 
biliary organs are present, or where the bowels are loaded with 
bilious and other saburral matter. (Richter.) Where these objec- 
tions to its use do not exist, and the skin is very hot and dry, and 
violent pain in the head, with delirium, is present, cold water thrown 
on the patient will often produce prompt and manifest abatement 
of the febrile symptoms. It is, notwithstanding, a good general rule 
to delay the cold affusions until evacuations both by venesection and 
by the bowels have been premised; and, above all, they must never 
be used imless the skin be dry and above the natural temperature. 

During the period of convalescence, mild tonics — such as infusions 
of cinchona, gentian, columbo, or serpentaria, will generally assist in 
restoring the tone of the digestive organs. The bowels must not be 
suffered to remain constipated ; and the diet should be simple, mild, 
and digestible— such as animal broths, rice, barley, a little boiled or 
broiled mutton, lamb, or tender beef. 



CHAPTER VII. 



YELLOW FEVER. 



Si/nont/mes. — Typhus Icterodes; Maladie de Siam ; Bulam Fever; 
Vomitus Prieto. — Causes. 

Yellow fever has been the theme of interminable discussion and 
controversy — a theme which has drawn forth the best and the worst 
feelings of the human heart— which has furnished motives, on the 
one hand, for the most active exertions of philanthropy and self-de- 
votedness, and, on the other, for all the bittterness and uncharitable- 
ness of feeling which man, in his most degraded moments, is capable 
of manifesting. 

[* Here also our south-western friends astonish us by the enormous doses of 
quinine which they throw into the stomach. From 10 to 30 and even 60 grains 
are given in this crisis at a dose, and repeated until the febrile symptoms yield. 
Some, however, are compelled to believe that the article must have been hugely 
adulterated to admit of such profusion. — Mc] 
VOL. I. — 10 



146 YELLOW FEVER. 

There is no form of fever more variable in the violence and cha- 
racter of its symptoms than the present one. In the seasoned and 
acclimated inhabitants of those regions where the disease is endemic, 
it is often as mild as ordinary bilious fever. But in the young and 
robust, who have not yet been seasoned to the climate, it seldom 
fails to make its attack with an overwhelming force ; commencing 
and terminating in death, often within forty-eight hours, and some- 
times sooner. 

The disease usually begins with a sudden feeling of giddiness, pain 
in the back, loins, and extremities, faintness and debility, with slight 
creeping chills and nausea. After a period varying from a few to 
twelve hours, these symptoms are succeeded by a sudden develop- 
ment of vehement arterial reaction, accompanied with a dry and in- 
tensely hot skin, flushed face, red eyes, extreme headache, tormenting 
thirst, intolerance of light, pain in the loins and lower extremities, 
a sensation of weight and tension at the stomach, white, and some- 
times clean tongue. Towards the end of the first twenty hours of 
fever, the patient begins to vomit frequently, particularly after taking 
drinks. The ejections consist, at first, of such fluids, only, as may 
have been taken into the stomach ; but after these have been thrown 
ofl", bile, often in abundance, is brought up, varying in colour from 
pale yellow to dark green, and frequently so acid as to excoriate the 
fauces and lips. The heat and tenderness in the epigastrium now 
increase, the countenance assumes an indescribable expression of 
distress and hopelessness ; there are great restlessness and sighing, and 
more or less delirium usually supervenes. In some cases slight 
pain is experienced on swallowing ; " and about this time an urgent 
sensation of hunger often comes on, and a remarkable want of power 
in the lower extremities, resembling partial paralysis." This pa- 
roxysm lasts, commonly, from twenty-four to thirty-six hours, but in 
some instances, considerably longer ; and then all the symptoms, 
with the exception of the nausea and the vomiting, greatly abate — 
the pulse returning to its natural standard, and the skin acquiring a 
moist and temperate condition. So complete, indeed, is the remission 
in some cases, that the patient is induced to flatter himself that all 
danger is now passed. More commonly, however, the patient re- 
mains in a state of tranquil indifl'erence, amounting to a sort of stupor, 
without any apparent concern as to present or future situation. This 
is an ominous calm; for, after a few hours, the pain and burning 
sensation in the stomach return with increased violence ; the vomit- 
ing becomes frequent and distressing — the fluid brought up containing 
minute flakes or flocculi, resembling the crust washed from a port- 
wine bottle, but little or no bilious matter. The desire for cool drinks 
is extremely urgent, but every thing which is swallowed is imme- 
diately rejected by the stomach, with great force. The eyes and skin 
about the neck and breast now acquire a yellow hue. This second 
paroxysm continues, commonly, from twelve to thirty-six hours, and 
is succeeded by a new train of symptoms, which mark the last or 
third stage of the complaint. The pulse now sinks in frequency, 
force, and volume; the tongue is dark-brown or black; the vomiting 



YELLOW FEVER. 147 

becomes almost incessant, and exceedingly forcible, the matter thrown 
up consistmg of a black ropy fluid resembling coffee grounds sus- 
pended in a glairy liquid. The extremities become clammy and 
cold ; and the acrid or burning sensation in the stomach, acquires a 
most distressing degree of violence. Diarrhoea usually occurs at this 
period — the discharges being green or black ; " and the patient often 
complains of being unable to pass his stools, from a want of power in 
the abdominal muscles." By this time the whole surface of the body 
is a dirty yellow colour ; and hiccough, hemorrhages, violent deli- 
rium, coma, insensibility, or convulsions, sooner or later termhiate the 
patient's sufferings in death. 

Such is the ordinary course of this fatal malady. In many instances, 
however, the attack is much more overwhelming ; the patient being 
seized at once with loss of muscular power, and general oppression 
of the nervous system — falling down as if stunned with a blow. In 
other instances, violent and furious delirium, or mania, ushers in the 
disease, terminating in a few hours in insensibility and convulsions. 
Sometimes the disease commences and proceeds to a fatal termination 
in so insidious a manner, that the patient himself and those about 
him are scarcely aware that he is much indisposed. In such cases 
there is, however, always a remarkable change in the expression of 
the patient's countenance, as well as his usual temper and habits. 
In almost all instances of this disease, the countenance is expressive 
of intense anxiety and despair during its early period, and of gloomy 
or sullen abandonment in the last stage. 

The period at which the skin begins to assume a yellow colour, is 
very variable. It sometimes occurs within the first forty-eight hours, 
and sometimes not until the fourth or fifth day. Various opinions 
have been expressed with regard to the immediate cause of this 
yellow hue of the surface. Some ascribe it to the serum rendered 
yellow by dissolved red globules of the blood, and efl'used under the 
cuticle. Dr. Fordyce attributes it to the superabundant secretion 
of sebaceous matter by the glands of the skin; and Dr. Saunders 
supposed it to depend on a peculiar stat« of the lymph in the sub- 
cutaneous cellular tissue. Many, however, maintain, and with cor- 
rectness, I think, that the yellow hue, in question, is of an icteric 
character, depending entirely on the deposition of bilious matter 
under the cuticle. 

The black matter thrown from the stomach in the latter period of 
this disease, does not consist of bile, as was once generally supposed. 
but of minute flakes of coagulated blood suspended in the gastric 
mucus, produced by sanguineous exhalation from the abraded sur- 
face of the mucous membrane of the stomach. The black matter 
discharged in some of the higher grades of bilious and typhus fevers 
difl'ers essentially from the " black vomit" of yellow fever. The 
former will dissolve in water, and communicate a deep bilious tinge 
to it; whereas the black matter which forms the black vomit of the 
present disease, consists of small insoluble flakes which are held 
suspended in a viscid fluid, and will not communicate a yellow or 
greenish tinge to water when agitated with it. " In taste also thev 



148 YELLOW FEVER. 

differ. The black matter which occurs in common bilious fever, is 
always intensely bitter ; but that which is thrown np in yellow fever, 
is either insipid or acid."* (Bancroft.) 

Post-mortem appearances.— The stomach and liver are the organs 
upon which the disease exerts its principal force. The former, espe- 
cially, alwavs shows tlie strongest marks of previous inflammation 
and its consequences. Its coats are often thickened, and the mucous 
membrane is always stronsly injected, abraded, and in many parts 
gangrenous, or totally disorganized. The duodenum and small in- 
testines also almost invariably exhibit marks of inflammation. In 
many of the more aggravated cases, the liver undergoes much struc- 
tural derangement. Dr. Chisholm has found the liver " in a dissolved 
or putrid state or sphacelated, and of the consistence, feel, and colour 
of rotten cork, or full of abscesses." Dr. Physick rarely found the 
liver much diseased, but the stomach was always inflamed and gan- 
grenous in parts.t 

Causes. — In relation to the origin and mode of dissemination of 
yellow fever, physicians have been at great variance ; and the subject 
is still much disputed, although the weight of good testimony is 
greatly on the side of its miasmatic or domestic origin. After an 
attentive examination of the principal observations which have been 
published on this subject, it appears, indeed, difficult to adopt any 
other opinion than that which alleges its origin from miasmatic efflu- 
via, " exhaled from masses of public filth containing putrescent mat- 
ter, generated under a high range of temperature." That this is the 
case, seems to he sufficiently demonstrated by the following circum- 
stances: — 1. Yellow fever always appears in the lowest and most 
filthy parts of towns ; and those localities in which it is most preva- 
lent, are in the immediate vicinity of marshes or soils favourable to 
the production of miasmata. 2. Yellow fever never occurs in cold 
seasons — a high range of atmospheric temperature being essential to 
the generation of its cause. 3. Heavy rains, storms, and the super- 
vention of cold weather, never fail to put an immediate check to the 
disease. J 4. Yellow fever always appears simultaneously, and is in- 
termixed with bilious remittents. Dr. Ramsay states, that in the yel- 
low fever of Charleston, in 1804, "neglected intermittent frequently 
terminated in yellow fever." Dr. .Rush also states, in relation to the 
yellow fever in this city in 1802, that "intermittents, the mild remit- 

* Mv. Lyon, staff surgeon in the Island of Dominica, says that the black matter 
ejected from the stomach in yellow fever, is invariably very strongly acid. He 
ascribed the black colour of the blood to the action of muriatic acid on it ; for it is 
this acid, which, according to the investigations of Prout and others, is secreted 
by the stoniach in a state of disease, "■ Having made the experiment of adding 
muriatic acid to blood, the colour of the blood was instantly changed to a deep 
black, and when diluted with water, presented a liquid, which I should have 
declared from mere inspection, to be black vomit."' — Lond, Med. and Phys. 
.Journ., 1829. 

f New York Medical Repository. 

X Rush's Medical Inquiries 



YELLOW FEVER. 149 

tent, the inflammatory, bilious, and the malignant yellow fever, have 
in many instances all run into each other ;"* and he observes that 
Dr. Saunders, nearly a century ago, noticed this conversion of marsh 
and yellow fever into each other. Yellow fever is, moreover, always 
most severe in the immediate vicinity of those localities which favour 
the generation of marsh miasmata. Dr. Caldwell, speaking of the 
yellow fever of this city in 1803, says, '• as the fever receded from the 
low ground and malignant atmosphere of Water street, it became 
more and more mild and manageable till its evanescent shades in 
Second street were, in many instances, much lighter than the common 
remittent of the country." During the prevalence of the yellow fever 
in Baltimore, "the bilious or remitting fever in its ordinary form, 
prevailed in that town and continued uniil it was gradually lost in 
the severer form of yellow fever as the season advanced." (Davidge.) 
5. The miasmatic origin of the disease may be inferred also from the 
fact, that the recurrence of it has often been, in a great measure, pre- 
vented by removing the sources of pestiferous exhalations, in situa- 
tions where it formerly prevailed, almost annually, to an alarming 
extent. Our own city may be cited as a prominent example of the 
efficacy of cleanliness in preventing the occurrence of this disease. 
(Bancroft.) If these views be correct, in relation to the origin of the 
disease, we are forced to reject the opinion so stoutly maintained 
by some, of its being in any respect contagious. Indeed, if yellow 
fever did possess the power of generating its own virus, and commu- 
nicating itself by contagion, the fact, as Dr. Bancroft observes, must 
liave been proved ten thousand times by the most irrefragable testi- 
mony, and yet there is, perhaps, no incontestable case on record 
where the disease was thus comnumicated. The city hospitals esta- 
blished in the neighbourhood of this city and at New York, furnish 
lis with a striking refutation of the supposed contagious nature of this 
disease ; for, in no instance, was the disease communicated to those 
who were employed about the sick. The same observations were 
made at the encampment near Baltimore, during the prevalence of 
this disease in that city in 1819. The recent very ample investigation 
of this subject by Dr. Chervin, has resulted in a mass of testimony,, 
which can scarcely leave any pretext for doubting the non-conta- 
gious nature of this disease. But, although yellow fever be not con- 
tagious, it may, no doubt, be introduced into seaport in ships Unques- 
tionably, a pestiferous miasm may, under favourable circumstances, 
be generated in the holds of ships while navigating in hot climates 
which, when suffered to escape at the wharves, may give rise to the 
disease in question. When the miasmata are thus introduced, how- 
ever, the disease engendered by it will not prevail epidemically, but 
only among those who approach the infected vessel, or the cargoes, 
and will disappear entirely when these are removed to a distance. 
(Bancroft.) The sporadic cases which occurred at the Wall, about 
1804, at Perth-Amboy, in 1811, at Middletown, in Connecticut, in 
1819, and at New York, in 1824, were distincdy traced to vessels that 

* Medical Repository for 1802. 



150 YELLOW FEVER. 

had recently arrived from warm climates. The circumstances of the 
ship Ten Brothers, at Boston, in 1819, afford a strikmg example of 
tiie production of deleterious miasm in the holds of ships, capable 
of producing yellow fever.* This vessel having arrived at Boston 
on the first of August, a number of persons went on board while 
the cargo was being discharged ; and out of these, twelve individuals, 
living in various parts of the city, were seized with malignant fever, 
nearly all of whom died. The disease was not, however, commu- 
nicated to a single person of those who visited the sick. 

Observation would seem to show, that those who had once suffered 
an attack of this disease, are afterwards, in a great degree, insuscepti- 
ble of another attack. In hot climates, where the disease is endemic, 
persons recently arrived from more temperate latitudes are almost 
exclusively obnoxious to this disease. The acclimated are, in a great 
degree, exempt from its attacks, and when it does occur in such in- 
dividuals, it almost always is of a comparatively mild and tractable 
character. The influence of the remote cause of this form 6f fever 
is greatly promoted by intemperance, excessive exercise in the sun, 
exposure to a damp and cold night air, and, in short, by whatever is 
capable of debilitating either the whole system, or deranging import- 
ant organic functions. 

Treatment. — If yellow fever has been a fertile subject of dispute 
in relation to its pathology and cause, it has afforded no less scope for 
contention with regard to its remedial management. Whilst some 
strenuously recommend a prompt and energetic treatment, others, 
condemning the lancet, mercury, and active purgation, advise nothing 
but the mildest and most soothing remedies. From a careful estimate 
of the best authorities on this head, however, it would appear that the 
chances of success are on the side of an energetic plan of treatment. 
This disease is highly phlogistic, and gastro-enteric inflammation is a 
very common occurrence — more especially in young, robust, and un- 
acclimated subjects. In cases where the arterial reaction is vehement 
in the onset of the disease, general blood-letting is often promptly 
and conspicuously beneficial. To obtain the full advantages which 
this evacuation is capable of affording, it must be early and very 
efficiently practised. Those who have employed blood-letting with 
the greatest success, are unanimous in restricting its use to the first 
stage of the disease. Dr. Robertson, in his account of the yellow 
fever of New Orleans, states, that during the first twelve hours, he 
frequently drew from fifty to sixty ounces of blood;t and Dr. Belcher 
bled to the extent of from fifty to eighty ounces in the first stage, with 
much advantage.^ In a disease so impetuous in its attack, and so 
apt to develop local inflammations, much, and often every thing, 
depends on an early and powerful antiphlogistic impression on the 
system. Where the reaction of the heart and arteries is vigorous, 
the blood should be sutTered to flow until fainting approaches, "for it 

* Medical Recorder. 

t Johnson on Tropical Climates, vol. ii. 

X Edinburgh Med. and Surg. Journal, 1825. 



YELLOW FEVER. 151 

is not only by unloading tlie vessels, but by the shock also which it 
gives to the system, that blood-letting proves so serviceable in inflam- 
matory fevers." Dr. Anthony Musgrave states, that as soon as the 
febrile reaction was developed, after the invasion of the disease, he 
derived the greatest benefit from the immediate and rapid abstraction 
of blood, to an extent limited less by the quantity than by its decided 
effect upon the action of the heart and arteries.* Dr. Rush, as is 
well known to the profession of this country, was a zealous advocate 
for blood-letting in the disease. " I paid no regard," he says, " to the 
dissolved state of the blood, when it appeared on the first or second 
day of the disorder, but repeated the bleedings afterwards in every 
case when the pulse continued to indicate it." " In a disease like 
this," says Dr. Robertson, " where the danger is frequently imminent 
in twelve hours, it is often surprising to see how much its apparent 
character may be altered by active depletion." A host of other able 
practitioners might be cited in behalf of the usefulness of this practice. 
In those instances of the disease, however, where the nervous system 
appears to be in a manner overwhelmed by the remote cause of the 
fever, when the patient exhibits an air of confusion or intoxication, 
with great agitation, " and a dash of wildness gleaming at intervals 
over his agonized features;" when he complains of little or no head- 
ache, but is impatient and irritable, yet oppressed ; and after the first 
days sinks down with a careless expression of resignation — in such 
cases blood-letting is wholly inadmissible. Here we must rely chiefly 
on the prompt and liberal administration of calomel with a view to 
its salivant operation. 

The etficient abstraction of blood in the commencement of the disease 
serves not only to break down the violence of the phlogistic excite- 
ment, but often contributes materially towards allaying the excessive 
irritability of the stomach, frequently so distressing in this malady. 

Purgatives, also, are highly useful remedies in this disease, though, 
like blood-letting, their good efi"ects are almost entirely confined to 
the early periods of the disease. Calomel and jalap, in doses of ten 
grains of each, was a favourite purgative with Dr. Rush. As calomel 
is, however, very generally admitted to be one of our most useful 
remedies in this disease, both on account of its purgative eft'ects and 
its specific constitutional influence, it will be better to exhibit it by 
itself in doses of from ten to fifteen grains every three or four hours, 
and to promote its purgative operations by laxative enemata, after 
the second or third dose has been taken. In this way copious alvine 
discharges will generally be effected, and the system early brought 
under the mercurial influence. Should the bowels, however, not be 
sufficiently evacuated by these measures, a dose of Epsom or Glauber 
salts ought to be administered. When the bowels have been thus once 
freely evacuated, they must be kept in a loose state by means of the 
milder laxatives ; such as Seidlitz powders ; small portions of the 
saline purgatives, or the occasional use of enemata. It should be 
observed, however, that mercury, with a viev/ to its constitutional 

* Treatise on the Yellow Fever of Antigua. 



152 YELLOW FEVER. 

operation, can seldom be serviceable, so long as the arterial action 
remains unsubdued in the commencement of the disease. Indeed, 
almost all attempts to produce ptyalism under such cucumstances 
are fruitless. Decisive blood-letting in cases of this kuid must be 
regarded as an essential preliminary to the use of mercurials. In 
cases of less vehement grade of febrile reaction, where the disease 
assumes more of a congestive character, the early induction of sali- 
vation is particularly desirable— and our principal object should be to 
produce this effect as speedily as possible. Dr. Musgrave observes, 
"that in the more concentrated form of yellow fever, experience 
leads me to believe that mercury, administered with a view to its 
salivant effects, may be judiciously dispensed with. But there is a 
form of this disease which, from its insidious approach, is peculiarly 
calculated to lull the patient into mistaken security," and thus to baf- 
fle, in its subsequent progress, the best directed efforts ; and this form 
is undoubtedly treated with great success by the rapid induction of 
ptyalism.* 

In cases where the febrile reaction is strongly developed, the skin 
is always extremely hot and dry during the first period of the dis- 
ease, and nothing is more refreshing than sponging or ablutions with 
cold water under such circumstances. Most writers prefer pouring 
it forcibly on the patient's body. Dr. Johnson observes, that " the 
greater the force with which the water is applied, the more benefit 
will be derived from it."t When the head is much affected during 
the first stage, considerable benefit may be obtained from cold appli- 
cations to the shaven scalp. Bladders partly filled with water con- 
taining a lump of ice, is the most convenient and effectual mode of 
applying cold to the head. For the same purpose blisters are recom- 
mended by some, but their usefulness in this respect is very question- 
able, and certainly much inferior to the application of cold, so long as 
the arterial reaction is vehement. Draughts of cold water are gene- 
rally very grateful to the patient, and have the effect often of mo- 
derating the heat, predisposing to perspiration, and of relieving the 
gastric distress. (Johnson.) Emetics are very generally, and with 
justice, condemned in the treatment of this disease. The gastric 
irritability and tendency to inflammation is so great in this affection, 
that mischief would almost inevitably result from the operations of 
this class of remedies. Nevertheless, we are told by Dr. M'Arthur, 
that where the disease commences with diarrhoea or dysenteric 
symptoms, emetics may be IVequently given with considerable advan- 
tage. Besides the means already mentioned for allaying the extreme 
irritability of the stomach, and restraining the vomiting so distressing 
m the disease, we may also derive much advantage from the appli- 
cation of leeches or blisters to the epigastrium, more especially alter 
the impetus of the circulation has been in some degree moderated by 
an eflicient bleeding. When the disease has passed on to the second 
period, we must depend on the use of mild aperients, diaphoretic and 

* Edinburgh Med. and Surg. Journal, 1827. 

t Influence of Tropical Climates, vol. ii, p. 182. 



CONTINUED FEVER. 153 

cooling beverages, enemata, cold affusions when the skin is hot and 
dry, and calomel, in reduced doses. A great deal, however, of the 
success of our remedial efforts depends on the proper management 
of the disease in tlie first period. As a diaphoretic, we may use the 
spiritus mindereri, or the saline effervescing draught. When, after 
the second exacerbation, the pulse and temperature sink, recourse 
should be had to the active tonics — and of these, the cinchona or 
quinine is the most efficient. The latter, especially, seems to have 
done. much good in this disease.^ These articles should be adminis- 
tered in as large and frequent doses as the stomach will bear. Dr. 
Musgrave resorted to the cinchona in the less vehement cases, with 
much good effect, as early as the first remission, having previously 
evacuated the bowels thoroughly. From five to ten grains of qui- 
nine may be given every hour or two during the remissions, and it 
may be given in conjunction with calomel, during the first periods of 
the disease. 

In the latter stage of the disease, the bark, quinine, wine, and am- 
monia, constitute almost the only remedies that can be employed with 
any prospect of advantage. Stimulants, however, are not so well 
calculated to do good in the sinking stage of this form of fever, as in 
that of typhus. The spirits of turpentine has also been recommended 
in the treatment of yellow fever, but it does not appear that its powers 
are sufficiently valuable in this respect to entitle it to much attention. 

It is proper to state that many of the West India practitioners adopt 
a plan of treatment far less energetic than the one just detailed. They 
employ little else than mild aperients, with copious draughts of acidu- 
lated drinks, enemata, and external cold applications. 



CHAPTER VIII. 

CONTINUED FEVER. 



Although the varieties of fever which are arranged under the 
present general head are termed continued, \n contradistinction to the 
forms of fever considered in the two preceding chapters, yet, with the 
exception of the ephemera, di fever strictly continuous or unremitting 
in its course, is in reality a phenomenon of the rarest occurrence. 
Whether the operations of the animal economy be carried on in a 
state of health or of disease, regular periodical fluctuations appear 
constantly to obtain in the excitement or actions of the system. In 
every form and variety of fever, there seems to exist a natural tend- 
ency in the general morbid excitement or symptoms, to remit or abate 
in their violence at some period during the day ; and this remission, 

* Journal des Auslandishen Literature, &c. Von Drs. Julius and Gerson. 



154 CONTINUED FEVER. 

in perhaps ninety-nine cases out of a hundred, occurs during the 
morning. In the fevers denominated continued, however, these tem- 
porary abatements in the violence of the symptoms are generally sHght, 
and frequently very transient; they usually occur very early in the 
morning, and seem to be the result of the abstraction of the stimulus 
of light, sound, &c., during the night, in conjunction with the natural 
tendency of the actions of the system to abate at this period. 

Continued fever occurs under a variety of prominent modifications, 
and under every grade of febrile excitement, from the feebly and 
sinking reaction of typhus, to the vehement and tumultuous actions 
of synochal fever. Agreeably to this circumstance, it has been cus- 
tomary to divide continued fevers into sthenic and asthenic, or 
inflammatory and typhus. That there exists a very material differ- 
ence between the low fevers denominated typhus, and those usually 
termed inflammatory, is quite obvious. The term inflammatory, 
nevertheless, does not seem to be strictly appropriate as a distinctive 
appellative in this place ; for that irritated excitement which consti- 
tutes fever is always necessarily inflammatory in its general charac- 
ter, whether the reaction be feeble and sinking, or vigorous and ardent. 
Mere grade of energy or activity is to be regarded as an accidental 
and variable quality of inflammatory excitement. Fever consists 
essentially in an irritated action of the sanguiferous system, and this 
irritated condition may be connected either with increased or de- 
creased energy of the vital powers. In pure synocha, the heart and 
arteries are in a state of morbid action, with increased powers of 
acting; whilst in typhus fevers the general irritated excitement is 
connected with fundamental debility of the vital powers. In either 
case, however, the irritated vascular action is essentially phlogistic, 
and equally prone to give rise to local inflammations. The diversi- 
ties which occur in the general character of continued fevers, depend 
mainly on the differences which occur in relation to the degree of 
vital energy enjoyed by the system, and this diversity in the general 
energies of the system itself, would seem to depend on the greater 
or less degree in which the nervous system becomes implicated in 
the disease. The brain is the fountain whence the animal economy 
draws its powers of action ; and whenever this source of the vital 
forces becomes injured or impeded in its operations, debility, corre- 
sponding to the degree and character of the cerebral aflection, will 
be manifested in the actions of the system. In the high and vigorous 
synochal fevers, there are rarely any considerable manifestations of 
cerebral disturbance ; whereas, in all those fevers which are attended 
with prostration and feebleness, the brain and nerves are generally 
prominently disordered throughout the whole course. 

There exists no small degree of difficulty in arranging continued 
fevers under such heads as will exhibit a distinct and comprehensive 
view of all the prominent modifications or forms in which they are 
wont to occur. In relation to the grade of febrile excitement, fevers 
may be divided into three principal varieties : namely, .s^nocAff, sy7io- 
chus, and typhus. 

1. Synocha. — This head embraces all those fevers which are con- 



CONTINUED FEVER. 155 

spicuously inflammatory, both in relation to their general and local 
phenomena. They are usually divided into idiopathic and symp- 
tomatic ; the former, constituting what is generally termed simple 
inflammatory iewQX', and the latter, embracing those fevers which 
result from acute local inflammation. Hardness, quickness and ten- 
sion of the pulse, are essential characteristics of synochal fever; but 
in relation to the size and activity of the pulse^ there exists great 
diversity in the different varieties of this grade of fever. In simple 
inflammatory fever the pulse is full, vigorous and hard ; whilst in 
some of the phlegmasia, in acute gastritis, enteritis and peritonitis, its 
volume is usually small, although its firmness, tension and quickness 
are conspicuous, and the necessity of prompt and vigorous depletory 
measures extremely urgent. The blood in synocha is thicker, and 
contains a smaller proportion of serum than in health, and is disposed 
to separate speedily and very completely into its constituent parts. 
The crassamentum becomes dense, concave, or cupped on its superior 
snrface, and coated with a thick layer of yellowish fibrin. The albu- 
menoid, or coagulable portion of the serum, does not become con- 
densed when subjected to the action of heat, alcohol, &c., but is con- 
verted into a white pap-like matter. Boiling water poured into the 
serum of blood taken from a patient labouring under synocha, con- 
verts it into a whey-Uke fluid, resembUng a solution of soap in water, 
without any coagulated flakes.* 

In synocha, the general energies of the system manifest no prone- 
ness to prostration, so long as the fever retains its simple character. 
The powers of vital resistance continue to the end, with no material 
impairment. When general fever of the synochal grade passes into 
a low or typhoid state, it is either in consequence of inordinate san- 
guineous depletion, or of the supervention of cerebral inflammation, 
or the occurrence of inflammation and gangrene in other organs. 

Simple continued fever of the synochal grade, is rarely attended 
with conspicuous symptoms of sensorial disturbance, or cerebral irri- 
tation; nor is it common to meet with signs of gastro-intestinal irri- 
tation in cases of this kind. Fevers, however, rarely preserve the 
simple synochal character throughout their whole course. In most 
instances, local inflammation supervenes in some part or other. When 
the inflammation falls upon a fibrous structure, or upon one of the 
solid viscera, the energy of the febrile reaction will be increased, or 
at least sustained ; but when it happens to appear in the mucous 
membrane of the alimentary canal, the brain generally becomes more 
or less oppressed, and the general powers of the system tend to a 
state of prostration. 

The secretions in synocha are almost universally diminished in 
quantity. Cold or atmospheric vicissitudes, and a high degree of 
solar heat, are almost the only general causes of this grade of fever. 

Synochus. — This grade of fever is intermediate between the purely 

* Reil. iiber die Erkentniss, &c., der Fieber. Band, i, s. 494. See also Par- 
mentier and Deyeux's Memoir in Reil's Archives fiir die Physiologe and B. 1. 
No. 3, s. 5. 



156 CONTINUED FEVEK". 

synochial and the typhus varieties of fever, and constitutes by far 
the most common modification of febrile reaction. It is the grade of 
fever which occurs in intermittents, remittents, biUous fever, and the 
common continued fevers which arise from cold and from gastric 
irritation. The pulse of synochus fever is active, more or less full, 
frequent, compressible, and free from unusual tension or hardness. 
The blood itself rarely differs perceptibly from its natural character, 
being devoid of the above-named inflammatory characteristics. The 
system is much less able to resist the influence of debilitating 
causes than under the preceding grade of fever. It will bear a 
degree of depletion while labouring under synocha, which, in a fever 
of the synochus grade, would produce the utmost degree of prostra- 
tion. 

Synochus is employed here as indicating merely a certain grade 
of febrile excitement, and not as constituting in itself a distinct form 
of fever. The reaction of the heart and arteries is only one of the 
series of morbid phenomena v/hich constitutes fever, and the same 
grade of vascular reaction occurs in maladies essentially distinct from 
each other. So far, indeed, as the mere action of the heart and 
arteries is concerned, fevers differ from each other only in degree; 
or, to adopt the language of Parry, in the greater or less momentum 
of the blood. It is in the capillary system of vessels, that the funda- 
mental morbid condition resides, which establishes the essential dif- 
ference of febrile diseases. The morbid excitement of the capillaries 
in a case of small-pox must be very different, one should think, from 
that which occurs in this system of vessels in remitting fever, and 
both may nevertheless be attended with the synochus grade of febrile 
reaction. 

Typhus. — This grade of fever is lower than the preceding one, 
the vital powers being more prone to sink, and, in general, much 
less able to resist the influence of debilitating remedial measures. 
It is characterized by a weak, small, quick, and generally frequent 
pulse. In some instances, however, of a typhous state of fever, the 
pulse is nearly natural in frequency and fullness ; but softness and 
feebleness are seldom absent, except in the commencement of the 
disease. An early disturbance of the sensorial powers, and a train 
of various nervous symptoms, almost universally attend fevers of the 
typhous kind. 

There are three apparently very distinct varieties of typhus fever. 
One of these varieties is characterized by what may be called a highly 
nervous state of the system — the patient manifesting along with a 
weak condition of the vital powers, a peculiar degree of nervous 
excitability and excitation, and an active state of the sensorial func- 
tions. This constitutes what was formerly usually described under 
the name of nervous fever, the typhus nervosus, pyrexia nervosa, 
neuropyra, typhus cum erethismo, and the febris nervosa simplex 
of authors. 

Another variety of typhus fever in connection with the deficient 
or sinking energies of the system, is characterized in its proo-ress by 
phenomena which have been generally regarded as indicati^ve of a 



STNOCCTA, &C. 157 

tendency to putridity ; the pulse, at first moderately full and active, 
soon becomes soit, fieeble, sometimes frexixient, and at others slower 
than natural, the skin is pale dingy, or sallow, its heat elevated, and 
of the kind called calor mordax, or in some instances nearly natural, 
and sometimes even below the natural standard. The breath, secre- 
tions, and exhalations are offensive to the smell; petechise, extra- 
vasations, colliquative hemorrhages from the gums, the fauces, the 
eyes, the bowels, &c., ensue towards the conclusion of fatal cases. 
This variety of typhus fever has been described under various de- 
nominations; such as f. colliqiiaiiva, f. putrida sanguined , f.pu- 
trida simplex, f. sepedogenetica, f. adynamica, typhus putridus, 
synochusputridiis, pyrexia myoica, pyrexia denophlebica, f. hsema- 
toseptica, septopyra, putrid fever, putrid nervous fever, typhus 
gravior, S,'C. 

There is a third variety of low fever, which, along with its radical 
tendency to prostration, is strongly characterized by a very conspicu- 
ous torpor of the sensorial, intellectual and general nervous func- 
tions. Its first stage is often attended by the synochus grade of 
vascular reaction, whilst the second stage is marked by torpor, great 
prostration, and feeble arterial action. Its different stages are more 
definite in their duration, and its essential phenomena succeed each 
other in a more regular order than those of other continued fevers. 
This constitutes the genuine typhus — the typhus contagiosus of 
authors — a form of fever which by many is believed, and I think 
with correctness, to be radically diverse from every other form and 
variety of febrile disease. 

Having made these general remarks on the principal grades and 
modifications of continued fevers, 1 pass on to the consideration of 
particular forms of fever. 



Sect. I. — The Synochal grade of Idiopathic Fever, or Simple 
Inflammatory Fever; Febris Irritativa ; Pyrexia Sthenica; 
Febris Vasorum; Inflammatoria; Enechia Cauma. 

This variety of continued fever is attended with the highest grade 
of febrile excitement, associated with increased irritability, as well 
as increased power of action in the heart and arteries. The premo- 
nitory stage is always short, the fever coming on suddenly with dis- 
tinct chills or rigors, the febrile action is rapidly developed, the whole 
surface becoming speedily intensely hot,* the pulse full and vigor- 

* The heat of the skin is of the kind usually called burning, in contradistinc- 
tion to that peculiar biting or acrid heat which occurs in typhus fevers, termed 
calor mordax. By laying the hand on the skin of a patient labouring under inflam- 
matory fever, the sensation of heat communicated is at first very considerable, but 
ou suffering the hand to remain for a short time, the sensation of heat gradually 
diminishes, until it seems to the touch but little above the natural temperature of the 
body. In typhus, on the contrary, the longer the hand is suffered to be in con- 
tact with the patient's body^ the more pungent and perceptible does the heat (calor 



158 SYNOCHA, OR 

ous, and rarely above one hundred and twelve in a minute, the face 
flushed and turgid, the eyes suffused, sparkling, and unusually sensible 
to the hght, the temples" and carotids throbbing, the head painful, the 
mouth and throat very dry, the breathing oppressed and hurried, the 
thirst for cold water very urgent, the tongue covered with a white fur, 
the bowels torpid, the urine very high-coloured, and small in quan- 
tity, the skin dry, harsh and suffused with a slight blush, and the ears 
morbidly sensible to sounds. Delirium is not a usual occurrence in 
this variety of fever; but when it does supervene it generally be- 
comes extremely violent, and greatly increases the unfavourableness 
of the case from its dependence, generally, on cerebral inflammation. 
The blood, when drawn, exhibits the inflammatory character already 
mentioned, i. e., the buffy coat,* cupped crassamentum, a paucity of 
serum, &c. 

These symptoms usually suffer regular remissions and exacerba- 
tions ; the former occurring in the morning, and the latter in the 
evening, until they finally terminate entirely under some critical eva- 
cuation. Simple synocha, or inflammatory fever, very rarely con- 
tinues beyond the ninth day, and still more rarely beyond the four- 
teenth, and not unfrequently terminates its course as early as the fifth 
or seventh day. When the termination occurs about the seventh 
day, the symptoms usually go on increasing in violence to the fourth 
or fifth day ; and when the disease is prolonged to the fourteenth day, 
the increase generally continues to the ninth, or perhaps the eleventh 
day. 

The resolution of inflammatory fever is almost invariably accom- 
panied by general and free perspiration, together with its never-fail- 
ing concomitant, a reddish or pale sediment in the urine. In some 
instances, a slight hemorrhage, particularly from the nose, accom- 
panies the crisis. In general, these critical discharges take place a 
few hours after an evening exacerbation, and this exacerbation is 
often ushered in by a slight chill. 

Inflammatory fever does not, however, often continue its course 
throughout in the regular and simple form which has just been de- 
scribed. Topical inflammations, of more or less intensity, very sel- 
dom remain wholly absent in the progress of the disease. The human 
system is rarely in such a condition as that some organ or structure 
is not in a state of predisposition to inflammation ; and there can 
scarcely be a circumstance better calculated to produce inflammation 
in a part thus predisposed than the very greatly augmented momen- 
tum and peculiar condition of the blood which exist in this variety 
of fever. When local inflammation supervenes in the course of a 

mordax) become, and the biting or acrid sensation of heat remains in the hand 
even after it is removed from the patient. 

* The buffy coat, which occurs in inflammatory fevers, differs from a some- 
what similar appearance observed sometimes on the blood of typhus patients. 
The former is of a uniform yellowish colour, and very tenacious whereas the 
latter is brittle, of a paler yellow, and presents an iridescent appearance reflect- 
ing some of the colours of the rainbow when held in certain positions to the li"ht. 



SIMPLE INFLAMMATORY FEVER. ' 159 

simple synochal fever, the general aspect and disposition of the dis- 
ease will, of course, be considerably altered. Sometimes the brain 
and its meninges become inflamed, at an early period of the disease ; 
but this occurrence is much less common in the synochal than in the 
synochus and typhus grades of idiopathic fever. Occasionally syno- 
chal fever, after having continued for a day or two, becomes compli- 
cated with rheumatic inflammation ; and in some instances inflam- 
mation occurs in one or more of the thoracic or abdominal organs. 
In general, the more the brain becomes affected, either by inflamma- 
tion or sympathetic irritation, the more apt will the system be to sink 
into a state of prostration or oppression. When the febrile reaction 
is extremely vehement, or the system habitually delicate and feeble, 
simple inflammatory fever sometimes exhausts the vital energies, and 
passes into a low or typhoid state. 

The constitutional predisposition to synochal fever would seem to 
consist in a vigorous condition of the vital powers, robust health, 
activity of the digestive and nutritive functions, and an irritable ple- 
thoric habit. Persons between the fifteenth and fortieth year of age, 
of a sanguineo-athletic temperament, appear to be most liable to 
fever of this vehement character. In early infancy, and in old age, 
simple inflammatory fever is not so often found to occur as during 
the intermediate periods of life. 

Causes. — The exciting causes of inflammatory fever are very 
various. This grade of fever may be produced by cold, atmospheric 
vicissitudes, high solar heat, the intemperate use of spirituous liquors, 
too free an indulgence in high-seasoned and irritating articles of food, 
the sudden suppression of natural or habitual evacuations, excessive 
corporeal exertions, a draught of cold water when the body is heated 
by exercise, violent passions, mechanical injuries, &c. 

Of all these causes of synochal fever, however, cold is by far the 
most common. It is from the extensive influence of this febrific 
cause that continued fevers of a synochal grade are so common in 
cold and variable climates, and during the cold and changeable months 
of spring and autumn in the temperate latitudes. During the sum- 
mer months we seldom meet with general fevers of a very phlogistic 
character ; and pure synochal fevers are perhaps still less common in 
the intertropical climates. Prevailing northwest and northeast winds 
are particularly favourable to the occurrence of inflammatory fevers. 
So remarkably is this the case, that typhus fevers will sometimes as- 
sume, for a time, a decidedly phlogistic character, if the wind shift 
suddenly from a southern to a northern point. May not the electric 
changes of the atmosphere have some agency in the production of 
this effect ? From the influence which atmospheric vicissitudes and 
sudden variations in the direction of prevailing winds are sometimes 
found to have on patients and convalescents confined in close cham- 
bers, or even in bed, this supposition does not seem to be improbable. 
There are, indeed, some writers who contend that a superabundance 
of electricity in the atmosphere constitutes the cause of epidemic in- 
flammatory fevers. Hopf observes, that fevers of this kind are always 
most apt to prevail during those seasons and meteorological conditions, 



160 SYNOCHA, &C. 

when the atmosphere is most charged with the electric fluid. Reil thinks 
that electricity often contributes considerably to the production oj 
phlogistic fevers by increasing the general irritability of the system.* 

It may be observed, however, that the grade or modification of a 
fever does not depend so much on the character of the remote or ex- 
citing cause, as upon the peculiar condition of the animal si/stem at 
the time the cause exerts its morbific influence. Thus, the same de- 
gree of cold may produce a low or typhoid fever in one, and a vehe- 
ment inflammatory fever in another individual— a circumstance which 
proves unequivocally that such diversities depend mainly, and often 
wholly, on the peculiar predisposing condition of the body itself. 

If of two individuals seized with fever from the same atmo- 
spheric vicissitude, one be especially prone to inflammation of the 
brain or of the mucous membrane of the alimentary canal, and the 
other to inflammation of the fibrous and serous structures, or be 
wholly free from any local predispositions of this kind, the fever will 
most probably early assume a low or typhoid grade of vascular re- 
action in the first, whilst in the latter it will be apt to retain its vigor- 
ous synochal character throughout its course. 

When speaking of the general character and etiology of fever, I 
observed that in simple inflammatory or synochal fever, the principal 
febrific irritation is, probably, located in the vascular system — that is, 
in the internal membrane of the heart, arteries, and capillaries. In 
those general inflammatory fevers which arise from the influence of 
cold, at least, this is probably the case ; for, in instances of this kind, 
besides the internal congestions and inequilibrium of excitement re- 
sulting directly from the impressions of this cause, a large proportion 
of the recrementitious elements of perspirable matter must remain 
mingled with the blood, (unless speedily removed by the vicarious 
action of some other emunctory,) and necessarily impart to this fluid 
qualities which are not natural to it. Most assuredly the retention 
of materials which have become useless to the system, and for whose 
constant elimination nature has provided so extensive a series of 
emunctories as the cutaneous exhalents, cannot be long tolerated by 
the animal economy with entire impunity. The blood is the natural 
stimulant of the sanguiferous vessels, and we must believe that its 
stimulating qualities are naturally in due and harmonious relation 
with the sensibility and irritability of its appropriate vessels. When, 
therefore, in consequence of suppressed perspiration, this fluid be- 
comes surcharged with the elements of recrementitious perspirable 
matter, its natural relations with the heart, arteries, and capillaries will 
be destroyed, and irritation more or less intense must almost necessarily 
ensue. Why such a cause should produce typhoid fever in one, sy- 
nochus in another, and pure synocha in a third individual, we may 
not be able to ascertain ; but the grade of fever is, no doubt, deter- 

* Hopf, Dissertat. sistens rudimenta theor. de principio febres inflam. epidemica 
gignente. Reil, iiber die erkentniss und kur dur Fieber. Band. i. s. 501. See 
also Gautier's work, entitled Commentatio medica de irritabilitatis notione natura 
et morb. p. 21. 



COMMON CONTINUED STNOCHUS FEVER. 161 

mined by the particular condition of the system in relation to acci- 
dental or habitual debility, local disorder or predisposition, tempera- 
ment, modes of living — in short, every thing which constitutes a 
deviation from perfect health. 

That the degree in which 'the sensorium commune becomes impli- 
cated,' has an important share in determining the grade of febrile re- 
action, has already been observed in several places. It would, indeed, 
seem very reasonable to conclude, that as the powers of the system 
depend mainly on the regular supply of the nervous influence, the 
more the brain, its fountain, becomes involved in disease, the feebler 
will be the powers of the vascular and muscular systems. All low 
or typhoid fevers, in truth, are characterized by early and conspicuous 
manifestations of cerebral disturbance, and the prostration and ence- 
phalic disorder generally increase, pari passu. In fevers of the sy- 
nochal grade, on the contrary, the brain and nerves suffer but little ; 
and, when inflammation of the brain does supervene, the system and 
vascular reaction soon sink to a lower grade. 

The prognosis in simple inflammatory fever is, in general, favoura- 
ble. This, indeed, may be regarded as the least dangerous of all 
the varieties of continued fever, so long as it retains its simple form. 
When local inflammation supervenes, the danger will be more or less 
increased, according to the importance of the organ or structure in 
which the inflammation occurs, or the variety and force of its sympa- 
thetic connections, and according also to the intensity of the inflam- 
mation. When the breathing is free, and without cough or pain in 
the chest, and the abdomen neither tender nor tense to the touch, we 
may conclude that the fever is not of a dangerous character, from the 
almost certain absence of thoracic and abdominal inflammations. 
Slight delirium during the exacerbations is not to be considered as a 
very unfavourable symptom; when it becomes very violent, however, 
it betokens encephalic inflammation ; and, of course, is indicative of 
greatly increased danger. Richter says, that a very profuse discharge 
of limpid urine, occurring suddenly; liquid or watery discharges from 
the bowels ; and very copious sweats without sedimentous urine and 
abatement of the symptoms, constitute very unfavourable signs in 
synochal fever. 

The signs which announce a favourable change are, the occurrence 
of slight hemorrhage from the nose ; general perspiration, attended 
with pale urine, becoming turbid when cool ; and diminution in the 
frequency, hardness and activity of the pulse, and in the febrile tem- 
perature of the surface. 



Sect. JI. — The Synochus grade of Idiopathic Fever. Common 
Continued Synochus Fever [Synochus Simplex). 

The ordinary continued fevers, those which are most frequently 
encountered in practice, though phlogistic in their character, do not 
manifest that intense grade of inflammatory excitement and perma- 
nency of vital resistance which characterize the variety of fever de- 

VOL. I. — 11 



162 COMMON CONTINUED 

scribed in the preceding section. In the simple continued fevers 
.Avhich form the subject of the present section, there exists, as m pure 
synocha, strong febrile reaction ; but the vital powers are not suffi- 
ciently sustained to enable them to maintain this elevated and ener- 
getic grade of morbid excitement — and hence, although the fever may 
commence with a degree of vascular reaction and general strength 
differing but very little from synocha, yet, both the grade of febrile 
excitement and the general powers of life will soon decrease con- 
spicuously, and verge to the low or typhoid state. 

The principal sources of this modification of continued fever are, 
cold or atmospheric vicissitudes, and irritation or disorder of the ali- 
mentary canal and of the biliary organs. Cold, however, is decidedly 
the most common source of the ordinary continued fevers of the tem- 
perate and more northern latitudes. When the disease arises from 
this cause, it is generally more phlogistic in its early periods, than 
when it occurs as the consequence of gastro-intestinal disorder or 
other febrific circumstances. The status gastriciis of the German 
pathologists is, nevertheless, almost invariably present in every modi- 
fication of continued fever of the synochus grade. An early occur- 
rence of nausea, vomiting, foul tongue and disagreeable gastric sen- 
sations, are among the most frequent symptoms of common continued 
fevers. In this respect, common continued fever of the synochus 
grade differs from synocha or pure inflammatory fever ; the latter 
being but rarely attended by very manifest signs of gastric disturb- 
ance. 

Simple continued synochus fever occurs under various modifica- 
tions, many of which have been described by authors as distinct 
varieties of fever. The ordinary continued fevers of our cold and 
variable seasons, depending on the febrific influence of low tempe- 
rature or sudden atmospheric vicissitudes, occur under various grades 
of violence from the simple febrile state called a cold, to the most 
aggravated fever tending rapidly to cerebral oppression and fatal col- 
lapse. 

In the mildest modification, a slight and transient feeling of chil- 
liness is succeeded by a moderate increase of heat on the surface ; 
a white tongue ; some increase in the frequency, quickness and full- 
ness of the pulse ; corporeal and mental languor ; dryness of the skin ; 
more or less pain over the eyebrows; a red and slightly diminished 
urine ; slowness of the bowels, and disturbed sleep. In some instances, 
the appetite is but little impaired, but most commonly it is suppressed. 
This grade of fever generally passes off in a few days, under a gentle 
perspiration or moderate diarrhoea. 

The modification, however, which is especially designated by the 
naipfie of common continued fever, is by no means so mild in its symp- 
toms or so transient in its duration, and may be considered, in its 
more aggravated character, as one of the most formidable of general 
febrile maladies. This modification of the disease is generally ushered 
in by a distinct cold stage, characterized by great lassitude, restless- 
ness, a feeling of tension and confusion in'the brain, oppressed and 
anxious breathing, feebleness and quickness of pulse, a clammy 



SYNOCHUS FEVER. 163 

tongue, disgust for food, flatulency and frequently nausea, retching, 
or vomiting. This stage, alternating towards its conclusion with 
flushes of heat, often continues for many hours before the stage of 
excitement is fully developed. The skin now becomes hot, dry, and 
suff'used with a uniform, but slight tint of red ; the pulse more fre- 
quent, full and active ; the face flushed ; a dull, heavy, or throbbing 
pain is experienced in the head ; the patient is restless, morose, or 
peevish, and feels unable to fix his attention, or to exert his mental 
faculties; his tongue is at first white, becoming dry, harsh, and dark 
brown as the disease advances ; the urine is generally red, sometimes 
pale, and wholly without sediment ; the bowels are torpid, and the 
alvine discharges soft, and often of a clay-coloured appearance. 
There is, generally, from the beginning, some degree of intolerance 
of light and sound, and the carotids and temporal arteries usually 
beat strongly. These symptoms commonly go on for five or six days 
without any material changes, except the slight remissions and exa- 
cerbations which occur in the morning and during the night. Slight 
delirium commonly occurs during the night for the first five or six 
days ; as the disease continues, however, the symptoms of cerebral 
disorder become more and more conspicuous, so that, by the eighth 
or ninth day, it arrives at its acme, and either gradually declines 
under a favourable crisis, or passes more or less rapidly into a ty- 
photis condition or collapse, attended with almost constant delirium, 
partial stupor, dilated pupils, dry, foul and dark-brown tongue, sordes 
about the teeth, hurried breathing, subsultus tendinum, picking at the 
bed-clothes; the pulse becoming progressively weaker, smaller and 
more frequent, and the vital energies sinking more and more until 
death takes place about the fifteenth, or perhaps the seventeenth day, 
and sometimes not until a later period. 

In some instances of common continued fever, the symptoms of 
cerebral irritation are considerable at an early period of the disease, 
and the nervous or typhous stage supervenes rapidly and under a 
highly aggravated train of phenomena. With the development of 
the stage of excitement, which comes on slowly after a protracted 
and oppressive cold stage, strong manifestations of a cerebral disorder 
ensue. The patient evinces great aversion to light and cound ; he 
is tormented by uninterrupted watchfulness; his mind is §jFeatly con- 
fused; delirium comes on early, and soon becomes continuous and 
often violent ; the countenance is flushed ; the carotids beat strongly; 
the vital and voluntary powers are oppressed ; the skin is intensely 
hot; the whole surface of the body is frequently tender or sore to the 
touch, and transient darting pains are often experienced in various 
parts of the body. "An extreme irritability of the nervous system 
attends the development of the fever; the arms are tossed to and fro 
on the bed; the head is moved from side to side, and the position of 
the lower extremities frequently changed."* Flatulency and irri- 
lability of the stomach, with more or less of tenderness to pressure 
in the epigastrium, are rarely absent. The pulse is at first trequent 

* Armstrong on Typhus. American edition, p. 230. 



164 COMMON CONTINUED 

and active, but seldom very firm or tense. The typhous state gene- 
rally comes on as early as the fourth or fifth day, and m some 
instances much sooner. When this happens, the pulse becomes 
smaller and more frequent ; the previous high delirium passes into 
a low muttering raving, and, finally, into a completely oppressed 
state of the sensorium, tending rapidly to a general prostration of the 
vital powers. The patient now lies on his back; moans, with his 
mouth open, and the eyes turned up under the lids. The retina 
seems insensible (o light ; one eye appears smaller than the other, 
from paralysis of one of the upper lids ; the muscles of the face are 
variously agitated ; the pulse becomes extremely rapid and small; 
and a clammy but warm sweat breaks out. The extremities finally 
become cold, the urine and faeces are discharged involuntarily, and 
life ceases either gradually or suddenly in a paroxysm of convulsions. 

Dr. Armstrong very truly observes, that in this latter and aggra- 
vated modification of the disease, acute or subacute inflammation 
of the brain is unequivocally present " soon after the full emergement 
of the fever." He has not, however, paid sufficient attention to the 
same condition of the alimentary canal. In the early period, and 
even before the stage of excitement ensues, nausea, retching or 
vomiting, total disgust for food, and various other disagreeable sen- 
sations in the abdomen are scarcely ever absent ; and in the more 
advanced stages, tenderness or soreness on abdominal pressure, a 
tympanitic state of the bowels, a foul tongue, with red edges, indicate 
with sufficient certainty the presence of gastro-intestinal phlogosis. 
In some cases, subacute inflammation is developed in the respiratory 
passages, and occasionally also in other parts of the body, according 
to the accidental local predispositions which may exist. 

There are some other modifications of continued fever of the syno- 
chns grade, which it will be proper to notice in this place. When 
cold acts on a system which has been previously much under the 
influence of koino-miasmata, it will sometimes give rise to con- 
tinued fevers of a manifestly bilious, or what has been called gastric 
character. Lassitude, a feeling of weight, tension, and dull pain in 
the head, depraved or obliterated appetite, acid or bitter eructations, 
a sense of fullness and weight in the stomach and right hypochon- 
drium, a sallow or icterode countenance, a gloomy taciturn disposi- 
tion of the mind, transient pains in the abdomen, constipation, or 
bilious diarrhoja, with occasional slight creeping chills, are the phe- 
nomena which usually usher in the febrile attack. The heat of the 
skin rarely becomes very intense ; the pulse is full, wavering, active, 
but very compressible, and seldom above 112 during the first few 
days of the fever ; the tunica albuginea is tinged with bile, and in the 
progress of the disease a more or less icterode hue extends over the 
whole surface of the body. The skin is frequently moist about the 
heart and breast, but general or uniform perspiration hardly ever 
occurs before the resolution of the fever. The tongue is bitter, and 
covered with a thick yellowish slime, generally moist at first, but 
dry, rough, and dark brown in the latter stage of the malady. The 
urine is highly charged with bile and small in quantity. Nausea, 



STNOCHUS FEVER. 165 

retching and vomiting always occur, and the patient loathes all kinds 
of food; the desire for cool and acidulated drinks is generally urgent. 
The breathing is oppressed, and a short humid cough usually attends ; 
its course is seldom very protracted, but its tendency to the typhous 
state is almost always exhibited at an early period, and unless the 
disease be mild, or speedily subdued, delirium, with the whole train 
of nervous symptoms mentioned above, and great prostration super- 
vene by the fifth, seventh, or, at farthest, the ninth day. The remis- 
sions and exacerbations are always very conspicuous. 

There is still another modification of continued fever of the syno- 
chus grade, which arises from the united influence of a damp and 
cold air, deficient, innutritions, depraved and aqueous diet, mental 
depression, &.c. The premonitory stage is long, but the fever itself 
varies in duration from five or six days to so many weeks. The 
pulse is often nearly natural in point of fullness and activity, but 
generally somewhat accelerated; the thirst is moderate, the appetite 
weak or entirely lost ; the patient is torpid and drowsy ; and the 
eyes are dull and watery ; nausea frequently occurs, particularly in 
the morning; the heat of the surface is considerable; the tongue is 
white, slimy, and the taste is flat ; the urine is pale, crude, and 
moderate in quantity, and generally surcharged with mucus. As 
the disease advances the pulse becomes weaker, smaller, and more 
frequent ; delirium of a low muttering kind ensues, with hiccough, 
subsultus tendinum, and at last coma. The fever does not, however, 
always run into the nervous state. In some instances a general 
diaphoresis, and a mucous deposit in the urine, occur about the 
seventh or ninth day, and leads to a slow convalescence. There is 
generally more or less tenderness in the abdomen. 

All the foregoing modifications of continued fevers, but more 
especially the second, have been confounded with genuine typhus. 
Dr. Armstrong has pointed out the distinctive characteristics of these 
maladies, and though he has since changed his sentiments with re- 
gard to the etiology and essential nature of typhus, the diagnosis 
which he has given between these two diseases, is nevertheless 
founded, I think, on sound positions. 

In typhus the sensorial functions are earlier and more invariably 
disturbed, and the muscular prostration is greater than in the most 
common forms of continued fever. Mental depression or despond- 
ency, a sullen gloom of the countenance, and an almost insurmount- 
able apathy and disinclination to mental and corporeal exertion, are 
remarkably characteristic of typhus, and never very conspicuously 
present in simple continued fever of the .synochus grade. '< In com- 
mon continued fever, the patient generally has not much inaptitude 
of mind, often answers questions readily, and in a pretty firm voice, 
without much increased agitation of the breathing ; whereas in typhus 
the answers are mostly given with languid slowness and reluctance, 
and much speaking obviously disturbs respiration. In common con- 
tinued fever, the skin is usually of a brighter red than natural ; 
whilst in genuine typhus it is always more or less of a dusky, dingy 
colour. In typhus it has an early tendency to become brown and 



1#Q COMMON CONTINUED 

dry ; in the common continued fever it is always white, and often 
somewhat moist for the first week."^ To these may be added the 
sHght exanthematous efflorescence about the fourth day of the stage 
of excitement in typhus,! wliich is never seen in common contmued 
synochus; and the very peculiar smellj which exhales from the 
bodies of typhus patients, and which occurs in no other malady. 

When common continued fever of the synochus grade remains 
simple or uncomplicated with manifest local inflammation, it rarely 
assumes a low or a very dangerous character. Instances, however, 
do sometimes occur, which apparently, without any local inflamma- 
tion, continue under no very violent train of symptoms until the vital 
powers gradually yield, and the system sinks into a state of great de- 
bility and nervous mobility. These cases are generally prolonged to 
the fifth, sixth, and even eighth week. The tendency of all febrile 
diseases, however, is to produce inflammation in some part or other 
of the system; and in few diseases, perhaps, is this tendency more 
strongly expressed than in the more violent cases of the present form 
of fever. Although it cannot be maintained that local inflammation 
invariably pre-exists as the only immediate cause of that group of 
phenomena we term fever, it must nevertheless be admitted, that, as 
an effect, more or less of local inflammation is much more commonly 
present in febrile diseases than was formerly, and by many is still 
supposed. In common continued fever from cold, encephalic inflam- 
mation is by no means a rare occurrence. In the more violent and 
rapid instances of the disease, where continued delirium, at first furi- 
ous and then low and muttering, occurs, cerebral inflammation is, 
no doubt, always present. In nearly all those who die of this form 
of fever, the brain and its meninges exhibit marks of previous inflam- 
mation, such as efl'nsion of serum into the ventricles and on the sur- 
face of the brain, great vascularity of its membranes, redness, vascular 
turgescence, flakes of eff'used lymph, &c. 

Gastro-enteric inflammation, also, is a common occurrence in the 
severer instances of this variety of fever. Tenderness of the abdo- 
men to pressure — a constant disposition to lie on the back with the 
knees drawn up — a red and raw aspect of the edges and tip of the 
tongue ; intestinal tympanitis, accompanied with low muttering deli- 
rium, are phenomena very frequently met with in the advanced 
stage of synochus fever — phenomena which give unequivocal evi- 
dence of the presence of inflammation in the alimentary canal. In 
many cases, both the brain and mucous membrane of the intestinal 
tube are inflamed ; and this concomitance of cerebral and intestinal 
inflammation renders the disease in the highest degree unmanagea- 
ble and dangerous. Not unfrequently, however, the brain is the only 
organ which suffers inflammation. When the cerebral affection is 
unaccompanied by gastro-intestinal inflammation, the patient seldom 
sinks so rapidly into the typhoid state as when the fever is attended 

* Armstrong on Typhus, p. 261, first American edition. 

t Hildebrand on Contagious Typhus. 

% An Essay on Typhus Fever, by Nathaij Smith, M. D.. p. 26. 



SYNOCHUS FEVER. 167 

by both these local affections. Great prostration and conspicuous 
typhous symptoms, in common continued fever, are almost always 
associated with the above-named signs of gastro-enteric inflammation. 

The mucous membrane of the respiratory organs, too, generally 
suffers irritation or some degree of inflammation. More or less cough 
occurs in the majority of cases ; and in some instances the pectoral 
oppression and difficulty of respiration from this cause become a 
prominent and serious affection. 

Prognosis, — When symptoms of local inflammation do not super- 
vene, the disease generally yields to a moderately antiphlogistic treat- 
ment, and terminates favourably under a critical diaphoresis within 
the first two weeks. Early and violent symptoms of cerebral disor- 
der are indicative of much danger. Continued, low muttering deli- 
rium, picking at the bed-clothes, paralysis of one or' both of the upper 
eyelids, continued agitation and distortion of the muscles of the face, 
eyes turned up under the lids, &.C., betoken cerebral inflammation, 
and the utmost degree of danger. 

Great muscular prostration — constant position on the back— a small, 
extremely frequent and weak pulse, denote a state of collapse, from 
which recovery is extremely rare, especially when connected, as it 
almost invariably is, with manifestations of local inflammation. Ten- 
derness in the abdomen — a gurgling noise when fluids are swallowed 
— tympanitis, liquid and unnatural alvine discharges in the early 
periods of the disease, are always indicative of great danger. 

Treatment. — In the treatment of simple continued fever, whether 
of the synocha or synochus grade of febrile excitement, we have the 
following general indications to direct us in our remedial efforts. 
1. To diminish the general momentum of the circulation. 2. Tore- 
store the natural actions of the various secretory organs — above all, 
those of the skin, liver, and kidneys. 3. To equalize the circulation 
and obviate local determinations. 4. To remove from and out of the 
system, as far as may be practicable, every thing which has a tend- 
ency to irritate or unduly excite the system. 

Of these general indications, the first is, undoubtedly, of paramount 
importance, and should, lhei:efore, always receive the earliest atten- 
tion in fevers of high vascular excitement. This is, more especially, 
requisite in pure inflammatory or synochal fever ; for here almost 
every thing depends on the speedy reduction of the excessive arterial 
reaction. Blood-letting stands at the head of our means for reducing 
vascular action, or inordinate momentum of the circulation. What- 
ever may be the immediate cause of the increased action of the heart 
and arteries, there can be no safe measure which will so speedily and 
effectually diminish its violence as the abstraction of a portion of the 
circulating fluid. In order to obtain the full advantages which blood- 
letting is capable of affording in febrile diseases, it ought to be em- 
ployed to the extent of producing a decisive impression on the system 
in the early period of the malady. Blood may, indeed, be drawn 
with benefit at any period of the disease, provided the pulse be active, 
quick, dense or hard; but one decisive lileeding soon after the febrile 
excitement is developed, will generally do more towards subduing 



168 COMMON CONTINUED 

the violence, or shortening the"duration of the malady, than a much 
greater quantity of blood taken away at four or five less efficient 
bleedings practised at intervals throughout its course. In truth, the 
benefit derived from blood-letting does not depend so much on the 
quantity of blood abstracted, a^uponthe degree of impression made 
on the system by the evacuation ; and hence, 20 ounces taken at 
once will often do more good than double this quantity taken in small 
but repeated bleedings. « In venesection for the relief of an inflam- 
matory affection, our object is not simply to diminish the quantity of 
the blood, but also to diminish the action of the heart and arteries ; 
and it may be affirmed that twelve ounces of blood drawn from a 
large orifice so rapidly as to produce an immediate and decided effect 
on the pulse, will prove much more useful than a considerably larger 
quantity taken so slowly that the heart has time to accommodate itself 
to the loss/' and thus to resist the subduing influence of this mea- 
sure.* 

It is certainly a good rule in practice to accomplish our intentions 
with as little expenditure of theresources of the system as possible. 
In all inflammatory affections, therefore, the blood ought to be drawn 
in a full stream and from a large orifice, and suffered to flow until 
its influence on the system is unequivocally manifested in the sub- 
'dued action of the heart and arteries, and the feelings of approaching 
syncope. This rule is particularly important in the acute phlegma- 
sia! affections. By taking away the blood in this manner, we obtain 
a riiore decisive and permanent reduction of the phlogistic excite- 
ment, and with a smaller expenditure of the hlood than when the 
evacuation is less rapidly and efficiently made ; since in this latter 
case it must generally be frequently repeated before the desired re- 
duction of the vascular reaction is effected. There is another cir- 
cumstance which renders very efficient blood-letting in the onset of 
febrile diseases preferable to less decisive but repeated abstractions 
of blood. However much the system may be subdued by a copious 
bleeding in the commencement of a fever, the vital energies soon 
rally sufficiently to prevent dangerous prostration from this measure; 
but when the blood, though not copiously at a time, is frequently 
drawn, it happens, sometimes, that at last the system is suddenly 
prostrated into a state of collapse, out of which the most potent stimu- 
lants will hardly suffice to raise the patient. I remember, with pain, 
the unfortunate lot of an amiable and intelligent friend. He was a 
man of a healthy constitution, and fond of indulging in the pleasures 
of the table. He was seized with a simple synochal fever from cold. 
His physician bled moderately ; the fever went on unchecked ; he 
bled again and again daily ; after the seventh bleeding there was still 
too much quickness and tension in the pulse ; the lancet was inserted 
the eighth time, and the patient almost immediately sunk into a state 
of collapse. Stimulants, both external and internal, the most diffusive 
and potent, were now diligently applied, but all in vain ; he lived but 
a few hours longer. 

* Scudamore on the Blood. 



SYNOCHUS FEVER. 169 

In fevers of the synochal or highly phlogistic grade, almost every 
thing depends on the speedy reduction of the excessive vascular ex- 
citement. Prompt and decisive blood-letting is indispensable in 
fevers of this kind. In the ordinary continued fevers of a less vigour- 
ous character, or the syiiochus grade where local inflammation has 
not already supervened, it is not often necessary to draw much 
blood. One or two bleedings, to the extent of making an evident 
impression on the system, will generally moderate the arterial action 
sufficiently ; and in the milder instances of the disease, blood-letting 
may sometimes be wholly dispensed with. As the principal danger, 
however, in fevers of this kind, depends on the supervention of local 
inflammation, and as this is by no means an uncommon occurrence, 
even in fevers which at first appear to be mild, it is always best to 
moderate the general momentum of yie circulation at once, by an 
adequate bleeding in the commencement, in order to lessen, as much 
as may be in our power, the liability to visceral inflammation. In 
the treatment of every form of fever, the prevention, or the speedy 
removal of local inflammation, constitutes a chief object of reme- 
dial attention; and there is no general remedy, which answers this 
object more directly than the judicious employment of the lancet. 

In the employment of blood-letting the pulse must be our prin- 
cipal guide. The quantity and frequency of the bleeedings must 
be regulated chiefly by the state of the pulse, and particularly by 
the eflects produced on it by the evacuation. There are, however, 
various other circumstances, which it is of much importance to bring 
into view, in the judicious management of this remedy. The tem- 
perament of the patient, the age, sex, constitutional predisposition, 
mode of living, climate, habits, &c., all claim especial attention. A 
native of an intertropical country will, cxteris paribus, rarely bear 
the same extent of depletion as an inhabitant of a northern climate. 
Persons of a nervous or relaxed habit of body, sink much sooner 
from the loss of blood than the sanguineous and athletic. In very 
old people we must proceed with more caution in the use of the lan- 
cet than in the youthful and middle-aged ; nor can we in general 
take as much blood without detriment from the luxurious, indolent, 
and intemperate, as from the vigorous, active, laborious, and tempe- 
rate. 

The inflammatory or buff'y coat of the blood may, in general, be 
regarded as an indication for the further employment of the lancet. 
It is not, however, to be implicitly relied on as a guide in this respect. 
In rheumatic fever, for instance, the blood will often continue to ex- 
hibit the buff" after bleeding has been practised to the utmost allow- 
able extent. Nor are we to regard the disappearance of this pheno- 
menon after several bleedings, as an objection to the further use of 
the lancet, if the pulse continues to indicate its propriety. 

A hard, tense, or quick and corded pulse, will always justify the 
use of the lancet, whatever may be the general character of the dis- 
ease, or at whatever period of its course it may occur. In the com- 
mencement or early period of the disease, the blood should be suffered 
to flow until a strong impression is made on the system j but when 



170 COMMON CONTINUED 

bleeding is practised at an advanced stage of the fever, it will, in 
general, be most prudent to carry it to the extent of producing only 
a slight effect on the pulse, as a very decided impression might rea- 
dily precipitate the system into a fatal collapse, or at least dangerous 
prostration. . . 

As the bowels are almost invariably more or less constipated in 
the varieties of fever under consideration, and liable, therefore, to 
irritation from this source, they ought always to be early evacuated 
by suitable purgatives. Without doubt, the secretions which flow 
into the intestinal canal, in every variety of fever, become additional 
sources of irritation when suffered to accumulate ; and hence, simply 
with the view of removing these accidental supporters of febrile ex- 
citement, purgatives are important remedies throughout the whole 
course of acute diseases. In ^ynochal and the common continued 
fevers, however, purgatives are beneficial, not only by evacuating 
the irritating contents of the bowels, but in some degree also by their 
depletory and revulsive effects. The choice of the purgatives is by 
no means a matter of indifference in the treatment of the present 
variety of fevers. The saline purgatives are generally preferable on 
account of the usual mildness of their operation, and their tendency 
to allay febrile excitement, by their general refrigerant influence, 
independently of their evacuant effects. The sulphates of soda and 
magnesia are excellent aperients in fevers of a highly phlogistic cha- 
racter. They may be administered with peculiar advantage, accord- 
ing to the following formula : 

K. — Sulphat. sodae vel magnes. §11. 
Tart, antlmon. gr. i. 

Solve In aquae fontanse §x. M. ft. Of this solution a wlneglassful may 
be taken every hour, until purging Is produced. 

In the commencement of the fever, when there is reason to appre- 
hend the early occurrence of serious cerebral affection, a mixture of 
jalap and cream of tartar is an excellent purgative. Twenty grains 
of the former, with two scruples of the latter article, may be admi- 
nistered for this purpose. This mixture generally causes very copious 
serous stools, and thus acts at once as a strong revulsive upon the 
brain, and as an active depletory measure. 

In those. cases of continued fever which are attended with manifest 
derangement of the biliary organs, six or eight grains of calomel 
should be exhibited a few hours before the saline purgative is admi- 
nistered. Cremor tartar dissolved in tamarind water, or the Seid^ 
litz powders, constitute very excellent laxatives in inflammatory 
fevers, after the bowels have been once well evacuated by a more 
active purge. 

Useful, however, as purgatives most certainly are, in fevers of the 
character now under consideration, they may, nevertheless be as 
readily abused in the present, as in other forms of fever. Harsh, 
drastic, or very frequently repeated catharsis, seldom fails to do much 
injury by exciting great irritation or subacute inflammation in the 
mucous membrane of the alimentary canal, and, perhaps, also in 



STTNOCHUS FEVER. 171 

some degree, by disturbing the natural tendency of these fevers to 
terminate by a critical discharge from the cutaneous exhalents. After 
the first purge, which ought to be sufficiently active to evacuate the 
bowels well, the milder laxatives alone should be employed in such 
a way as to procure two or three gentle evacuations daily. These 
observations are made in reference to simple or general inflamma- 
tory or synochus fever; for, in many of the most dangerous phleg- 
masial diseases, very active purgatives are often decidedly beneficial 
by their revulsive efl'ects, as well as by their tendency to moderate 
general febrile excitement. Thus, in arachnitis, in peritonitis, in acute 
ophthalmia, &c., active cathartics often contribute very materially to 
the reduction of the malady. 

Diaphoretics are well calculated to do good in fevers of a high 
grade of excitement. Torpor of the cutaneous exhalents is generally 
the first link in the chain of morbid actions which take place in the 
development of these maladies, and continues often throughout the 
greater part of their course, unless overcome by the employment of 
suitable diaphoretics. In vain will we look for the subsidence of 
such a fever, so long as this important emunctory remains inactive. 
The benefits which accrue from this class of remedies are, however, 
by no means proportionate to the copiousness of the evacuation they 
produce ; for in almost every variety of continued fever, much more 
advantage usually results from a moderate and uniformly diffused 
diaphoresis, than from very profuse sweating. In the early period 
of inflammatory fever, it is generally extremely difficult, and often 
impossible, to procure more than a very partial and transient diapho- 
resis. Nevertheless, the remedies which are commonly employed 
to produce diaphoresis, possess the power of moderating febrile ex- 
citement, independent, apparently, of any evacuant effect; and hence, 
although we may fail in procuring an adequate discharge by the skin, 
considerable benefit will generally arise from the early and regular 
employment of such medicines. Nitre, which is one of our most 
valuable diaphoretics in inflammatory fevers, manifests also no in- 
considerable power in reducing the general phlogistic condition of 
the system. The same is still more conspicuously the case with 
antimony , and these two articles are accordingly almost universally 
employed in fevers of a phlogistic diathesis. Nitre and tart, anti- 
monii, are usually administered in combination, in doses of from ten 
to fifteen grains of the former, to one-eighth or one-tenth of the latter, 
every two or three hours. This combination, however, sometimes 
acts strongly on the bowels, and gives rise to irritation, tormina, and 
frequent watery stools. Such effects tend greatly to increase the vio- 
lence and danger of the disease, and must be speedily counteracted 
by mucilaginous drinks, and minute doses of calomel and ipecacu- 
anha. Thus : 

K. — Calomel, gr, i. 

Pulv. ipecac, gr, vii.—M. Divide into eight equal parts, of which one is to 
be taken every half hour or hour. 

This combination, when aided by mucilaginous diluents, seldom 



172 COMMON CONTINUED 

fails to subdue the gastro-intestinal irritation produced by irritating 
remedies or other offensive ingesta. This is a point to which great 
attention should be constantlv paid. The exhibition of nitre and 
antimony or cathartics, after the effects just mentioned occur, is ex- 
ceedingly improper, as it must almost inevitably increase the violence 
and dangerousness of the malady. It should always be recollected 
that the chief danger in fevers of this kind arises from the local in- 
flammations which are so apt to occur ; and our main object should 
be to prevent the occurrence of inflammation, or to subdue it as 
speedily as possible. 

I have usually preferred administering the nitre and tart, anti- 
monii, according to this formula, as being much less apt, I think, 
to irritate the stomach and bowels, than when given in the form of 
a powder. 
R. — Nitrat. potassae gij. 

Tart, antimonii gr. i. 

P. extract, glycyrrh. gij. 

Mucilag. g. arab. ^ss. 

Aquae foeniculi. 

Aq. fontanae aa ^iv. — M. ft. Dose — a tablespoonful every hour or two. 

Cullen was of opinion that the antiphlogistic effect of tart, anti- 
monii depends on the nausea, and consequent relaxation which it 
produces when taken in full doses ; but this opinion has not been 
confirmed by experience ; it being now very generally admitted 
that it possesses a sedative or contra-stimulant power, wholly inde- 
pendent either of an evacuant or nauseating effect. Of late this arti- 
cle has been much employed by Rasori and his followers as a contra- 
stimulant, in what may well be called enormous doses. It is asserted 
that when given in large a.nd frequent doses, to the extent of from 
twenty to thirty grains daily, it rarely produces emesis, and often not 
even nausea, but greatly diminishes the action of the heart and arte- 
ries, and general as well as local inflammatory action. In Italy the 
most violent inflammatory fevers are treated, and according to the 
published reports with success, by large and frequently repeated 
doses of this article, without any direct depletion whatever. Of this 
practice I can say nothing from my own experience. That it may 
be adequate to subdue inflammatory excitement can scarcely be 
doubted, but neither its safety nor its successfulness appears to me 
such, as to warrant the relinquishment of depletion, with the usual 
antiphlogistic auxiliaries in favour of its exclusive employment. In 
small doses antimony is a safe and an important medicine in the treat- 
ment of inflammatory fevers. From one-eighth to one-tenth of a 
grain every hour or two, will generally contribute materially to the 
reduction of febrile reaction, and rarely fail ultimately to excite the 
cutaneous emunctories. I have been led to believe that the diapho- 
retic and antiphlogistic effects of this antimonial are more certainly 
and conspicuously displayed when administered in a considerable por- 
tion of some bland nutritive or mucilaginous fluid, than when given 
in the form of powder, or an ordinary aqueous solution. One grain 



STNOCHUS FEVER. 173 

of tart, antimonii may be dissolved in a pint of barley water, and 
drank in the course of four or five hours. Antimony must be used 
very cautiously, however, in cases attended with symptoms of gastric 
irritability or irritation. Its salutary powers are most conspicuously 
displayed in the pure synochal fevers, although more or less benefit 
may be derived from its judicious employment in every modification 
of fever attended with an increased momentum of the circulation 
and a dry and preternaturally warm skin. ' 

James's powder, in small and repeated doses, is also an excellent 
antiphlogistic diaphoretic, in fevers of this kind. It may be given 
by itself, or in union with nitre, in doses of half a grain of the former 
with twelve grains of the latter, every two hours. Of all the seda« 
tive diaphoretic remedies I have yet employed, the most powerful 
is a liquid antimonial preparation, somewhat similar to the old dia- 
phoretic antimony in its composition, prepared by Mr. Edward 
Evans, an apothecary of this city. This preparation is but little 
known, although, from what I have frequently witnessed of its effects, 
I am fully satisfied that it is a peculiarly valuable remedy. Mr, Evans 
is the only person in this country who prepares this antimonial 
remedy, and no measures whatever have been taken by him, or by 
any one else, to bring it into notice. 

Digitalis in small and frequent doses, either alone or in combina- 
tion with nitre, will sometimes aid considerably in reducing excessive 
vascular action. From a quarter to half a grain, administered every 
two hours, rarely fails to make some impression on the pulse, in the 
course of forty-eight hours. It is particularly appropriate in those 
instances where, after due depletion and catharsis, the pulse remains 
quick, somewhat active and frequent, and where it may be doubted 
whether more blood may yet be prudently abstracted. 

Mercury is not applicable to the treatment of simple inflamma- 
tory fever. In common continued fevers of a less violent grade, 
especially in instances attended with biliary disorders, and in cases 
which become complicated in their course with subacute visceral 
inflammation, the mercurial influence will frequently afford important 
advantages. In no case, however, ought mercury to be administered 
with a view to its constitutional influence, before the general mo- 
mentum of the circulation has been considerably diminished by 
bleeding and purging. Where opportune and moderate evacuations, 
together with blisters, fail to arrest cases of common continued fever, 
attended with subacute inflammation, "calomel," says Dr. Arm- 
strong, " should be given as a salivant. On numerous occasions," 
he aflirms, " I have seen an evident improvement in visceral inflam- 
mations from the time that ptyalism took place. I must again 
observe, however, that mercury is salutary only in those modifica- 
tions of continued fever, where the general powers of the system and 
the action of the heart and arteries evince a tendency to a moderate 
grade of febrile excitement. Where the vital resistance and actions 
are vigorous, or where very acute and rapid visceral inflammation 
is present, nothing but the most prompt and efficient employment of 
the lancet can afford any reasonable hopes of success. In most 



174 COMMON CONTINUED 

instances of common continued fevers, however, there exists a radi- 
cal tendency to a typhoid state, and the inflammations which arise 
are usually of a slow or subacute character. In such cases mercury 
may be accounted as among our most useful remedies, when pre- 
ceded by proper depletory measures. It must also be observed that 
mercury can be usefully employed only in the early periods of the 
disease, anterior to the approach of collapse or cerebral oppression. 
I have generally preferred giving the calomel in two grain doses, 
with a few grains of ipecacuanha, every four or five hours, until the 
gums become slightly affected. I have often found the skin to 
become moist, the pulse softer and less active, and the symptoms 
generally to abate, as soon as the mercurial influence became per- 
ceptible in the gums. 

There are various other general antiphlogistic remedies of minor 
importance, which may be occasionally resorted to with advantage 
in the fevers under consideration. When the disease is in a great 
measure subdued, and the pulse continues to be somewhat quick, 
sharp, and irritated, and the skin rather dry and hot, the following 
mixture will generally act very beneficially : 

R. — Spirit, minclereri, ^vi. 

Spirit, nit. dulc. 3iiss. 

Vin. antimonii, gi^s. 

Syrup limonis, ^jj. 
S. Dose, a tablespoonful every two or three hours. 

In the early period of simple continued fever, when the skin is 
very hot and dry, considerable relief may be obtained from spong- 
ing the body with cool water. In fevers of a very high grade of 
excitement, a draught of cold water is not only always very grateful 
to the patient, but tends, moreover, to reduce, for a time, the exces- 
sive febrile heat, and to dispose to diaphoresis. In cases complicated 
with local inflammation, however, cold ablutions will rarely do 
good, and sometimes manifest harm. Cool acidulated drinks ought, 
indeed, to be freely allowed in synochal fever, so long as the skin 
remains dry. Lemonade, solutions of tamarinds, currant, black- 
berry or strawberry syrups, form very pleasant and useful beverages 
in febrile affections. When the surface is moist with perspiration, 
the drinks should be tepid. The mild diaphoretic infusions, such 
as elder-blossom tea, infusions of eupatorium perfoliatum, balm, 
marjoram, &c., together with spiritus mindereri, or spirit, nit. dulc, 
minute portions of tart. antim.,or the saline eff'ervescing draught, 
are appropriate and useful remedies in the latter periods of the dis- 
ease, when the febrile irritation is about declining under a gentle 
diaphoresis. 

Although tropical remedies are not particularly indicated in the 
treatment of simple or general fevers, yet as synochal and common 
continued fevers are apt to become complicated, during their progress, 
with visceral inflammation, local remedies often become indispensable 
to the safety of the patient. The brain and mucous membrane of the 
alimentary canal, are most frequently the seats of these secondary 






STNOCnUS FEVER. 175 

inflammations. In some instances, perhaps in the majority, both 
these structures become inflamed at once ; in others, one of them 
alone suffers inflammation. The occurrence of cerebral inflammation 
in common continued fever is always an accident of the most alarm- 
ing and dangerous character, and ought to be promptly and vigorously 
counteracted by every efiicient means in our power. In the more 
violent cases of the disease, symptoms of approaching cerebral in- 
flammation sometimes manifest themselves soon after the full deve- 
lopment of the fever, but in most instances, the inflammation does not 
show itself until about the fifth or sixth day of the disease. Where 
there is reason to apprehend the occurrence of cerebral inflammation, 
or where it has actually commenced, blood should be at once drawn 
until syncope approaches, and one or two brisk cathartics admi- 
nistered. Topical bleeding by leeching, is generally especially recom- 
mended in such cases ; but my own experience leads me to place 
much more reliance on cold applications to the bare scalp, with blis- 
ters on the back of the neck, and a few cups to the temples. As 
leeching, however, does not take up a great deal of time, nor prevent 
the use of these latter applications, it should undoubtedly be employed 
if leeches can be had. Whilst these applications are being made to 
the head, warm fomentations should be applied to the feet and legs, 
in order to cause as much revulsion from the brain as possible. It 
ought to be particularly kept in mind, that little or no benefit will be 
derived from any of these applications so long as the momentum of 
the general circulation remains preternaturally augmented. General 
blood-letting, to the extent of producing a v^ry decided impression on 
the circulation, should always precede the employment of leeching, 
cupping, or blisters, in fevers of high vascular excitement. From 
this precept, however, we must except tlie application of cold, which, 
in cerebral inflammation es])ecially, may be employed with great 
benefit, however vigorous the febrile action may be. The applica- 
tion of ice or iced water to the head, is, indeed, a very valuable 
remedy in fevers attended with cerebral inflammation. The hair 
should be cut oflT close to the scalp, and cold applications almost con- 
tinually made to the head, at the same time that the circulation is 
solicited to the inferior extremities by warm or irritating applications 
to the feet. 

The common practice in this country, of applying blisters to the 
scalp, is of very doubtful efficacy. From much attention to this 
subject I am satisfied that little or no benefit can be derived from 
the application of blisters to the top of the head in cases of cerebral 
inflammation.* Applied to the back of the neck, or between the 

* [This is no doubt true in the active or earlier stages of cerebral inflammation. 
But after extensive and protracted depletion, no remedy is more efficacious than 
blisters over the entire shaven scalp. I am confident that several lives have been 
saved under desperate circumstances by this remedy. I recollect one case where, 
on the seventh day of acute menigitis, after frequently repeated general and topi- 
cal blood-letting and severe purgation, the delirium and intolerance of light and 
sound yielded to a large blister over the scalp, which was left on for nine entire 



176 COMMON CONTINUED STNOCHUS FEVER. 

shoulders, however, they will often assist materially in reducing en- 
cephalic inflammation, and should certainly never be neglected in- 
such cases. 

When the inflammation is seated in the alimentary canal, leeches 
succeeded by a large blister should be applied to the abdomen ; and 
nothing but the blandest mucilaginous drinks allowed, with occasional 
laxative enemata. The usefulness of cold applications is almost 
wholly confined to encephalic inflammation ; for in gaslro-enteritis, 
they are wholly useless, and calculated rather to do mischief. In- 
stead of cold, warm fomenting applications ought to be employed in 
this latter inflammation. 

It should be observed that the mucous membrane of the intestines 
is frequently intensely inflamed, without the patient complaining of 
any pain in the abdomen. Ignorant practitioners never think of in- 
flammation unless they hear the patient complain of pain. I have 
known cases of continued synochus fever treated to within a few 
hours of their fatal termination, without the slightest suspicion, in 
the mind of the physician, of the existence of intestinal inflammation, 
because no pain was complained of by the patient, although the ab- 
domen was exceedingly tender to the touch, and the tip and edges of 
the tongue clean and florid. 

In all cases of general fever, it is of the utmost consequence to 
attend carefully to the state of the internal organs, more especially 
to that of the gastro-intestinal mucous structure. Firm pressure 
should from time to time be made on different parts of the abdomen. 
If the patient complain of much tenderness or pain when pressure is 
made, there will be reason to apprehend the existence of inflamma- 
tion ; and if, in addition to this sign, the tip and edges of the tongue 
are red and clean, the presence of mucous inflammation of the bowels 
may be deemed certain. Frequently, on examination, the abdomen 
is found so tender that even slight pressure gives rise to the severest 
suffering, although, without pressure, the patient does not complain 
of any pain. 

In examining the abdomen, care must be taken to press success- 
ively upon every part of the abdominal parieties. In some instances 
we may press firmly upon several parts without giving rise to much 
uneasiness, until we come to the region over the inflamed portion of 
the bowels, where the slightest touch will cause the patient to flinch 
or cry out. Even when the patient is incapable of expressing his 
sensations, from being in a state of delirium or stupor, we may gene- 
rally detect the presence of abdominal inflammation by watching 
the countenance while the pressure is made. If there is inflamma- 
tion, the countenance immediately assumes the expression of pain 
and suffering, on compressing the abdomen. During the whole 
course of the present variety of fevers, the strictest attention should 

days. This patient recovered without any relapse. In another case of acute 
hydrocephalus in a child attended with complete prostration, coma and dilated 
pupils, the same remedy, continued for several days, afforded unexpected and 
complete relief. — Mc] 



TTPHUS. 177 

be paid to the removal and exclusion of every thing which is capable 
of irritating or unnecessarily exciting the system". In synochal or 
inflammatory fever, the chamber should be kept quiet, cool, and ob- 
scure ; and besides the beverages already mentioned, and thin barley 
or toast water, no nourishment whatever should be allowed. This 
is a most important though very often much neglected requisite in 
the safe remedial management of fevers. The most judicious treat- 
ment, in other respects, is frequently rendered abortive by a want of 
proper dietetic regulations. 

Tonics, or stimulants, are very rarely necessary during convale- 
scence from inflammatory or common continued fever. They would, 
indeed, very generally prove prejudicial. For several days after the 
complete subsidence of the fever, the patient ought to refrain from 
solid animal food, and above all from high-seasoned articles of diet. 
Farinaceous liquids, and weak animal broths, taken in moderation, 
will in general be quite sufficient for the iirst four or five days of con- 
valescence. 



Sect. III. — Typhus. 

There is, perhaps, no form of febrile disease, concerning which 
physicians have expressed a greater variety of conflicting opinions, 
than typhus fever. Long an object of the deepest interest and atten- 
tion, it might well be presumed, that every circumstance calculated 
to illustrate its nature and remedial treatment, must have been abun- 
dantly noticed and accurately estimated. Whatever industry and 
carefulness of observation may have been bestowed on this subject, 
the result has not been very flattering, for even at this day, there ex- 
ists great discrepancy of opinion concerning many of the most im- 
portant points of its pathology and treatment. 

Without entering into a detail of the vague and arbitrary employ- 
ment of the term typhus, in the writings of both ancient and modern 
physicians, it will be sufficient to state, in limine, that typhus is here 
regarded as a peculiar form of fever, capable of propagating itself 
by contagion — commencing often like synochus, and passing into a 
state, characterized by a stuimed or torpid condition of the sensorial 
powers, with great prostration of strength and delirium. 

Symptoms. — {Fxexnomiory stage.) — A peculiar uneasy sensation 
in the pit of the stomach, want of appetite, slight giddiness and nau- 
sea, pale, shrunk, and dejected countenance, dull and heavy eyes, 
often tremor of the hands, and a general feeling of weariness, debi- 
lity, and disinclinalion to mental and corporeal action. These premo- 
nitory symptoms usually continue from three to six days, terminating 
in those which mark the stage of invasion — viz. : slight chills, alter- 
nating with flushes of heat; an entire disgust for every kind of food; 
tongue covered with a thin whitish fur ; considerable nausea, and 
sometimes vomiting : a quick, small, and irregular pulse ; a confused 
and heavy sensation in the head, and increased mental and physical 
depression. This stage generally occupies from six to twelve hours, 

VOL. I. 12 



178 TYPHUS. 

and terminates in the stage of excitement. The febrile heat now 
increases considerably, the face is slightly flushed, the pulse rises in 
strength and fullness, the skin becomes dry, the hps parched, there is 
considerable thirst for cool drinks, the tongue becomes more furred 
and slimy, the bowels are usually torpid, the mind is more confused, 
the patient fretful, restless and watchful, with an anxious expression 
of the countenance, the urine is small in quantity and reddish, the 
head feels heavy, much confused, and vertiginous; durmg the first 
two days of this stage occasional manifestations of slight delirium 
occur during the night. About the end of the second, or during the 
third day of this stage, slight catarrhal symptoms usually supervene 
—such as suffused and injected eyes, moderately inflamed fauces, 
somewhat painful deglutition, more or less oppression in the chest, 
attended generally with a short dry cough. There are often some ten- 
sion and tenderness in the hypochondria, more especially the right 
one. (Hildebrand.) Pains in the back, loins and extremities, are 
rarely absent in this stage, and in most cases a general soreness is ex- 
perienced throughout the whole body. Towards the close of the third 
day of the stage of excitement, there are usually much giddiness and 
sensorial obtuseness present ; the patient appearing, even at this early 
period of the disease, as if under the influence of some narcotic. The 
cerebral functions now become more and more disturbed, hearing 
becomes obtuse, delirium more frequent and considerable, and the 
general torpor gradually increases. Hildebrand asserts that a pecu- 
culiar miliary exantheme occurs on the surface about the fourth day 
of this stage, which he considers as essential to the perfect and regular 
development of the disease. The same observation is made by 
Hartman.* One of the most striking characteristic phenomena of 
typhus is the almost insurmountable aversion to corporeal and intel- 
lectual exertion, manifested throughout nearly the whole course of 
the disease. The patient moves slowly, and, seemingly, with great 
reluctance, and his answers to questions are hesitating, short and 
peevish. The stage of excitement generally continues about six or 
seven days, before it terminates in the stage of collapse, though this 
sinking stage sometimes supervenes at a much earlier period; and 
occasionally comes on a few days later. The occurrence of a collapse 
is manifested by the subsidence of the previous inflammatory symp- 
toms, and the supervention of great prostration ; feebleness and 

* In those seasons when typhus prevails most epidemically, and very remark- 
ably in the present (1827), it is very frequently attended by an eruption of the 
skin closely resembling what is seen in some of the contagious exanthemata, 
particularly measles. A majority of the cases treated by me in the hospitals dur- 
ing the present year had more or less of this eruption. It was most distinct and 
numerous in severe typhoid cases, but not confined to cases of any type. It was 
very irregular in its time of appearance and disappearance — seldom appearing, 
however, before the fourth or fifth day; sometimes not till the tenth or twelfth, in 
which last case, it was uniformly attended by an aggravation of the febrile symp- 
toms. Dr. Alison on the Epidemic Fever of Edinburgh; vide Edin. Med. and Surg. 
Journ.j vol. 28, p. 244. 



TYPHUS. 179 

greater frequency of the pulse ; a dry, brown, and eventually black 
tongue ; teeth and prolabia incrusted with black sordes ; a stunned, 
confused and deranged state of the sensorial functions, with more 
or less constant, low muttering delirium ;* total apathy and indif- 
ference to surrounding objects ; generally great difficulty of hearing ; 
floccitacio, subsultus tendinum, twitching of the muscles of the face, 
great difficulty of protruding the tongue, constant recumbence on the 
back, and gradual sliding down towards the foot of the bed from defi- 
cient muscular power; a peculiar biting heat of the skin called calor 
mordax, and finally, in violent cases, dark spots or blotches on the 
slirface, a deep guttural or sepulchral voice, hiccough, and a tympa- 
nitic state of the abdomen. Tenderness of the abdomen to pressure, 
is one of the most common symptoms, in the latter periods of typhus. 
(Hildebrand, Broussais.) During the collapse, the urine is rather 
copious, pale, and often foams like beer, when voided into a vessel ; 
there is, generally, also a manifest tendency to diarrhoea in the latter 
periods of this stage, the discharges being watery, acrid, and highly 
offensive: Towards the termination of this stage, particularly when 
it tends to a fatal end, coma, more or less complete, is seldom absent, 
from which, however, the patient may usually be roused for a few 
moments. The period of collapse generally continues from seven to 
nine days, terminating either in slow convalescence or in death. The 
occurrence of convalescence is announced by the appearance of a 
gentle and uniform moisture on the skin, a reduction of the acrid heat 
of the surface, a moist tongue cleaning along the edges, more copious 
and sedimentous urine, abatement of the delirium, and short intervals 
of repose, and in some instances moderate diarrhoea. In some cases 
these phenomena of a favourable crisis do not take place until the 
seventeenth or even the twenty-first day, but in the majority of 
instances they occur about the thirteenth or fourteenth day of the 
disease. The progress of convalescence is generally tedious, and the 
debility both of body and mind, after the total subsidence of the fever, 
is always very considerable. 

Such are the course and principal phenomena of simple typhus, 
in its regular progress. Deviations and various irregularities do, 
indeed, frequently occur, even in the simple form of the disease, but 
they are seldom such as to efface the peculiar character, or essential 
phenomena of the malady. 

Typhus, however, is subject to certain prominent modifications, 
which, as they require corresponding changes in the mode of treat- 
ment, require particular notice. In some instances the disease is 
early attended with internal visceral inflammation, a complication 
which adds considerably to the rapidity and danger of the malady. 
This modification constitutes the inflammatory typhus of Armstrong. 
The typhoid pneumonia, so extensively and fatally prevalent through- 
out this country, in the years 1811, 1812 and 1813, was of this kind. 

* During the low and tranquil delirium of typhus, the mind is usually occupied 
and tormented by some one prominent idea or object. Hildebrand compares it 
to the mental workings of a somnambule. 



180 TYPHUS. 

The brain, the lungs, the mucous membrane of the alimentary 
canal, the liver, and the peritoneum, are the parts most apt to be- 
come inflamed in typhus; and of these parts, the brain and intestmal 
tube are most frequently the seat of the inflammation. Most com- 
monly, the phlegmasial symptoms do not supervene, until the second 
or third day of the stage of excitement, though occasionally the local 
affection manifests itself much earlier. 

When the brain is inflamed there are generally deep and pulsating 
pain in the head; flushed countenance; throbbing of the carotids; 
redness and morbid sensibility of the eyes; irritability of temper; 
transient pains in the extremities ; great precordial oppression ; irre- 
gular respiration; continued watchfulness; visual illusions; early 
and almost unintermitting delirium ; a glairy and blood-shot appear- 
ance of the eyes ; contracted pupils ; intolerance of light ; gloomy 
and agitated countenance; continued m,oaning and coma. (Arm- 
strong.) 

When the lungs are inflamed, the ordinary symptoms of pneu- 
monia are superadded to those of typhus. Pain and cramps in the 
inferior extremities; or, pain along the course of the spine, with 
irregular and difficult respiration, (unconnected with pneumonic 
symptoms,) and a peculiar uneasy feeling in the pit of the stomach, 
indicate the existence of spinal inflammation. The signs of enteric 
inflammation are often much more obscure. Tenderness and ten- 
sion of the abdomen ; an anxious and disturbed countenance ; a very 
small, quick, and frequent pulse ; constant recumbence on the back; 
much retching or vomiting ; longing for cool drink ; a burning sen- 
sation in the pharynx; difficult deglutition and great prostration of 
strength, characterize this variety. The patient, however, seldom 
complains of pain in the abdomen, unless pretty firm pressure is 
made on its external surface, when his sufferings are, generally, 
strongly expressed, both by complaints and by the expression of his 
countenance. 

There is another modification of typhus, the congestive, which is 
characterized by the following phenomena : a want of febrile reaction, 
after the stage of oppression, the system remaining in an oppressed 
condition, throughout the whole or the greater portion of the course 
of the disease. The vital powers are overwhelmed and depressed, 
and the patient appears to sink, progressively, from the moment the 
disease commences until the vital action ceases altogether. In the 
more aggravated cases of this kind, there is, from the beginning, ex- 
treme lassitude and debility, attended with deep-seated pain in the 
head, with a feeling of weight and vertigo ; the face remains pale ; 
respiration is much oppressed and slow ; t1ie pulse is struggling, small, 
feeble, slow, and variable ; the skin relaxed, damp, and usually below 
the natural temperature ; the countenance confused, vacant, and anx- 
ious, the patient appearing as if stunned by a blow. The eyes are 
generally dull, watery, vacant, and often red ; the bowels at first tor- 
pid ; but in the advanced period of the disease often aflfected with 
watery diarrhcBa. In the commencement, the tongue is pale, slimy, 
becoming rough and brown afterwards. Towards the close, pete- 



\ TYPHUS. 181 

chioe, colliquative hemorrhages, and involuntary stools are apt to occur. 
Sometimes coma is among the first symptoms, and continues to the 
end of the disease ; and not unfrequently a complete state of insensi- 
bility and torpor supervenes soon after the disease makes its attack. 
(Armstrong.) 

Cause. — In relation to the cause of typhus, much difference of opin- 
ion exists among physicians. Whilst some maintain that it may be 
produced by any of the ordinary causes of fever,* others believe that 
it is essentially a specific disease, and dependent, exclusively, on a 
peculiar virus or morbific agent. Dr. Armstrong has advanced the 
opinion, that typhus is often generated by the same miasm that pro- 
duces remittents and intermittents ; an opinion, however, which does 
not appear to have obtained many advocates. It is, indeed, not to 
be denied, that when marsh miasmata, or, perhaps, any of the usual 
causes of fever, act on a system which has been depressed and debili- 
tated by the enervating influence of cold, want of nourishment, men- 
tal distress, &c., a low or typhoid state of fever will be developed; 
but the course and characteristic phenomena of such fevers do not 
accord with those which mark genuine contagious typhus. If koino- 
miasmata (malaria) were capable of producing typhus, we should 
find this disease (one might reasonably expect) among the prevailing 
forms of fever in all miasmatic districts, which, however, is contrary 
to general observation. During the years 1S22-23-24-25 and 26, 
miasmatic fevers were extremely common throughout nearly every 
section of this country ; and yet, typhus was but very rarely observed. 
There are, on the other hand, localities where typhus has very fre- 
quently prevailed with great severity, but where intermittents and 
remittents are almost unknown. Dr. Smith states, that " on the Con- 
necticut river, from Northampton in Massachusetts to its source, a 
distance of more than two hundred miles north and south, and on all 
its tributary streams, on both sides, for a hundred miles in width, there 
has been no instance of any persons having contracted the intermit- 
ting fever, from the first settlement of the country to the present time ; 
and yet typhus fever has prevailed more or less in every township 
within that tract of country." In confirmation of his opinion on this 
head. Dr. Armstrong affirms that remittents often assume the appear- 
ance and character of typhus; and that these two forms of fever 
resemble each other in many of their most striking symptoms. " Re- 
mitting fever," he observes, "is always attended with a simultaneous 
afi'ection of the brain, the mucous membrane of the respiratory pas- 
sages, the mucous membrane of the alimentary canal and of the liver 
— a combination of symptoms always present in typhus." If, how- 
ever, resemblances of this kind are to be admitted as evidence of 
identity of cause, we might, with equal propriety, refer small-pox, 
catarrhal fever — nay, almost every form of disease, to one and the 
same cause. The characteristics of typhus do not consist in any of 
these circumstances. With regard to the alleged conversion of re- 
mittents into typhus, it may be observed, that the former do, indeed, 

* Good's Study of medicine, vol. ii. Riel, Fieber-lehre, band. 2. 



182 TYPHUS. 

in some instances, assume a low or typhoid character ; but this may- 
be predicated of nearly every other variety of febrile disease, and 
cannot be justly urged as an argument in favour of the common ori- 
gin of the two'former diseases. 1 have myself known ten cases of 
ordinary bilious remittents, brought together in an illy ventilated and 
narrow'apartment, degenerate into low and putrid fevers of a highly 
fatal character. A system already suffering from a miasmatic disease 
may, no doubt, be 'brought under the influence of those morbific 
effluvia (idio-miasmata), which are generated by a number of persons 
crowded into narrow, close, and sordid apartments. It can scarcely 
be doubted, that when these two varieties of miasmata act concomi- 
tantly on the system, the product will be a form of fever neither 
distinctly typhus, nor yet remittent nor bilious in its character.* 

Whatever may be the discrepancy of opinion among physicians, 
in relation to the existence of a typhus contagion, all seem to be 
agreed upon one point .-—namely, that typhus is often generated by 
that species of miasmata which is evolved in very crowded, confined, 
and filthy apartments, by the decomposition of human effluvia. The 
records of medicine abound in examples of the production of typhus 
by the morbific effluvia generated in crowded and ill-ventilated ships, 
jails, hospitals, and the confined and sordid hovels of the poor. Al- 
though often unequivocally generated in this way, it is scarcely less 
certain that when once developed, typhus elaborates a peculiar virus 
or contagion, by which it may be afterwards communicated to those 
who come within the sphere of its activity. It should be observed, 
indeed, that there is much weighty authority extant against the exist- 
ence of a typhus contagion. As positive observations cannot, how- 
ever, be adequately countervailed by negative facts and speculative 
objections, we are constrained to give credence to the reality of such 
a contagion, by the vast body of direct testimony we have of the 
repeated propagation of this disease in a manner demonstrative of 
such an agency.t Wedekind states that, during the campaigns of 
the French against Russia, the typhus contagion, which was generated 
in the hospitals and houses crowded with prisoners and sick, was 
communicated to the inhabitants along the road by which the sol- 
diers returned ; and afterwards spread gradually from the road-side 
to the adjacent districts, until the disease became widely prevalent. 
The rout of the returning army from Poland through Germany, 
could be distinctly traced, by the desolating train of disease it left 
behind. 

Somewhat analogous to the narcotic poisons, the miasm or conta- 
gion of typhus possesses a specific tendency to benumb or diminish 
the sensorial powers, and to depress, generally, all the vital energies. 
In a state of vigorous health, with the powers of vital resistance 
unimpaired, the deleterious operation of the typhus contagion is much 

* Dr. Smith on the Etiology of Epidemics, New York, 1827. 

t Dr. Marsh's Dublin Hospital Reports, voh iv. In this memoir there are many 
cases recorded, which afford powerful evidence of the propagation of typhus by 
contagion. 



TYPHUS. 183 

retarded, and often entirely prevented. In an opposite state of the 
system, tiowever, when the moral and physical energies are depressed, 
by that combination of hardships and privations which attend sue- 
courless and hopeless poverty, in times of general distress, this morbific 
agent seldom fails, when once engendered, to manifest its deleterious 
powers. 

The typhus contagion, like that of small-pox, is capable of attach- 
ing itself to various substances, more especially to articles of clothing, 
and thus to retain its power of infecting for a long time. It is asserted, 
however, that clean articles of clothing are never rendered infectious 
by the deposition of this contagion — (Good) — an assertion which 
admits, I think, of some doubt. It is, indeed, sufficiently ascertained, 
that filth of every kind greatly favours not only the development, but 
the activity and preservation of this poison ; but we have no satis- 
factory grounds for denying that it may not attach itself to clothes 
not dirty, particularly woolens, and retain its powers of infecting for 
a considerable period. 

What length of time the typhus contagion may retain its powers 
of infecting, when deposited in fomites, cannot, perhaps, be definitely 
ascertained. Hildebrand thinks it seldom retains its activity more 
than about three months ;* but this, no doubt, depends greatly on 
various accidental circumstances — such as degrees of confinement, or 
ventilation, cleanliness, and the nature of the substance to which it 
becomes attached. Dr. Rush states, that he has known typhus pro- 
duced by the contagion which was left in a room six months after it 
had been occupied by patients ill with this disease. 

In a pure and free air, the typhus miasm extends but a short 
distance — perhaps not more than three or four feet from its source, in 
a sufficient degree of concentration to affect a healthy individual. It 
would appear (hat pure air is capable of dissolving or decomposing 
the particles of this contagion, and thus to destroy their power of in- 
fecting ; or, perhaps, as some maintain, the effects of free ventilation 
in this respect may depend chiefly, if not wholly, on the rapid dilution 
of the miasm in the air, and its consequent insufficient concentration 
to affect the system. Be this as it may, it has been well ascertained 
that there is but very little danger of becoming affected, in the cham- 
ber of a typhus patient, provided the air be freely admitted and clean- 
liness observed. In an impure and confined atn:tosphere, however, 
the miasm in question gradually diffuses itself throughout its whole 
extent, and retains a high degree of activity ; and hence, those who 
visit typhus patients in narrow, dirty, and close apartments are par- 
ticularly liable to become infected. 

Whatever be the virulence or activity of the typhus miasm, expe- 
rience has ascertained that its power of affecting the human system 
is greatly under the control of constitutional, as well as of accidental 
predisposilion to its deleterious influence. It would appear, even, 
that the condition of the organization which constitutes this predis- 
position is peculiar (analogous to that which constitutes the suscepti- 

*Ueberden Aiasteckenden Typhus, page 151. 



184 TYPHUS. 

bility to small-pox or measles, &c.) and independent of the mcidents 
of mere grade of constitutional vigour or health. It is asserted by 
Hildebrand, Hartman, and some other writers, that this susceptibility 
to typhus is greatly diminished by an attack of the disease ; so that 
the liability to a second attack is, for a considerable time, at least, 
much lessened, if not entirely removed. Independent of this consti- 
tutional or natural predisposition, there are various circumstances of 
an incidental character, which contribute materially to enhance the 
deleterious influence of this miasm. I have already adverted to the 
tendency which impure air, want of wholesome nourishment, excess- 
ive muscular action, despondency, and personal filth, have in favour- 
ing the operation of the typhus contagion. It would appear, more- 
over, that the predisposition to infection, from this cause, varies with 
the age of the individual ; for the occurrence of this disease in infancy 
and very advanced age is extremely uncommon. It is remarkable, 
says Hildebrand, that very young children, who otherwise are so 
very susceptible of contagious diseases, are extremely seldom affected 
with typhus ;* and it is almost as uncommon to meet with this dis- 
ease in very aged and withered individuals. No difl'erence, in this 
respect, obtains in relation to sex ; but it would seem that individu- 
als of a delicate and relaxed habit of body are more susceptible of 
the typhus infection than such as are robust, muscular, and well 
nourished. 

With regard to the proximate cause of typhus, we know but little 
that is satisfactory. Marcus and Clutterbuck maintain, that inflam- 
mation of the brain constitutes the primary and essential pathological 
condition of this disease. They assert, that traces of cerebral intiam- 
mation are almost universally detected, on post-mortem inspection — 
an assertion which is, indeed, very often confirmed in those who die 
of simple or inflammatory typhus, but rarely in such as have died of 
the congestive form of the disease. The early, and often severe pain 
in the head, as well as the heaviness, confusion, and sensorial dis- 
turbance manifested in this disease, are adduced, also, in confirmation 
of this opinion. That the post-mortem evidence of cerebral inflamma- 
tion in typhus, is, however, far from being so general as is asserted 
by these writers, is manifest from the testimony of various other in- 
telligent observers. Dr. Kirby, director of the anatomical theatre in 
Dublin, observes, that the brain, supposed by some to be the seat 
of inflammation in typhus, rarely exhibited the characters indicative 
of such a state. In some this organ was much paler than usual : in 
a very few instances, among a great number of dissections, was there 
any evidence of sanguineous or serous effusion.t The same obser- 
vations are made by Dr. M'Cartney, professor of anatomy; and also 
by Dr. O'Brien.J 

Broussais, on the contrary, regards gastro-enteritis as the proxi- 

*Loc. cit., p. 169. 

t Transact, of the Associat. of the Fellows and Licentiates of the King and 
Queen's College, Dublin, vol. ii. 
X Ibid. 



TYPHUS. . ' 185 

mate or primary pathological state of this malady ; and he, on his 
part, refers with equal confidence, to the appearances discovered on 
dissection, for proof of his doctrine. 

Hildebrand considers the proximate cause of the disease to con- 
sist in a condition of all the mucous membranes approaching to in- 
flanimation, which is propagated to the sensorium commune and the 
nerves. 

It may be observed, however, that although inflammation of the 
mucous membrane of the alimentary canal is a very common affec- 
tion in this malady, and in cases of a fatal tendency, perhaps very 
rarely absent, it is still exceedingly improbable that it constitutes the 
primary and essential pathological condition of the disease, and can- 
not, therefore, be regarded as its proximate cause. Such inflamma- 
tions occur, most probably, in the course of the disease, and should 
be viewed as one among the ordinary morbid consequences of the 
fever. The importance of attending to this condition of the intesti- 
nal canal, in a practical point of view, is by no means lessened by 
the supposition of its being consecutive; for, whether primary or 
secondary, its reduction or removal must constitute a very essential 
part of the remedial treatment. 

Prognosis. — To the experienced physician, the general course and 
degree of violence of the disease, in connection with the degree and 
situation of the internal local inflammation, will usually afford suffi- 
cient data for the formation of a probable prognosis. Observation, 
however, has made us acquainted with various particular pheno- 
mena, as being indicative, either of a favourable or fatal termination 
of tlie disease, and which it is of importance to bear in mind, in form- 
ing a prognosis. 

Among the symptoms which appear to indicate a favourable tend- 
ency of the disease, are : spontaneous vomiting during the first and 
second days of the disease, more especially when the unpleasant 
cephalic sensations are thereby abated ; slight hemorrhage from the 
nose, about the sixth or seventh day of the stage of excitement, is a 
good indication ; and moderate diarrhoea, at an earlier period, is like- 
wise favourable. Pringle asserts, that he has often known the dis- 
ease subdued by the early occurrence of gentle diarrhoea ; when the 
abdomen remains soft, and free from pain and tenderness to external 
pressure, it is a favourable sign. Moderate and quenchable thirst 
during the stage of collapse, is said to be much more favourable, 
than when the patient expresses no desire to drink. A moist tongue 
dnriiig the collapse is a good sign ; and so is a moderately free and 
not very frequent pulse. The most certaiu sign, however, of a fa- 
vourable termination, is derived from the state of the sensorial func- 
tions. If these are but slightly disturbed during the collapse, the issue 
will most probably be favourable. Most writers mention deafness 
as a good sign ; Hildebrand, however, has not found this observation 
confirmed by his experience. 

The unfavourable signs are : a change in the expression of the 
countenance at an early period of the disease; total want of thirst; 
violent delirium during the stage of excitement ; peripneumonic symp- 



186 TYPHUS. 

toms. But the most ill-boding of all the bad symptoms are : blind- 
ness; involuntary flow of tears; difficult deglutition; paralysis of 
the tongue; continued low muttering delirium; a very frequent, 
small and irregular pulse ; petechia ; distortion of the muscles of the 
face ; pain, or great tenderness of the abdomen ; meteorism ; con- 
tinued motion of the hands, and picking at flocks ; dysenteric stools; 
insensibility to active vesicatories ; aphtha in the mouth ; involun- 
tary colliquative stools ; colliquative hemorrhages, &c. After all, 
however, patients do sometimes recover from this disease after many 
of the most alarming of these symptoms have made their appear- 
ance.* 

Treatment.— Ixv prescribing for typhus fever, it is of the utmost 
consequence to bear in mind, that its different stages are character- 
ized by peculiar pathological conditions, each of which demands its 
corresponding modification of treatment. It is equally important, to 
attend to the general character of the disease, in reference to the three 
distinct varieties mentioned above — namely, the simple, the inflam- 
matory, and the congestive. A neglect of proper attention to these 
circumstances, has, no doubt, contributed much to the disputes which 
have existed, and still exist, concerning the mode of treatment best 
calculated to insure success in the management of the disease. There 
are physicians who, looking upon the employment of blood-letting 
in typhus as a practice always extremely hazardous, and very fre- 
quently ruinous, regard tonics and stimulants as the only appropriate 
remedies for its treatment ; whilst others, equally vehement in their 
opposition to the use of tonics and stimulants, go to the opposite ex- 
treme, and carry depletion to an extent, which cannot fail, in many 
instances, to cause irreparable injury. The truth is, that both stimu- 
lants and venesection are often indispensable in the treatment of this 
disease; and both may prove very injurious, when employed without 
due discrimination, at periods and under modifications of the disease, 
contra-indicating their use. 

During the former stage of the disease, the principal indication is 
to overcome the torpor of the extreme vessels of the surface, and 
to recall the circulation from the internal to the external parts. For 
this purpose, an emetic is, perhaps, the most efficient and beneficial 
means we possess. Vomiting excited by an emetic seldom fails to 
improve the condition of the skin, and to obviate the tendency to 
internal congestions. In many instances, indeed, the early adminis- 
tration of an emetic will interrupt the train of morbid actions and 
prevent the further development of the disease. Although especially 
useful in the cold stage of the disease, emetics may be used also with 
occasional advantage in the early period of the stage of excitement. 
Hildebrand, indeed, affirms that he has known decided benefit derived 
from the exhibition of an emetic as late as the fifth and sixth days 
of the stage of excitement; and the same observation is made by 
Pringle, Stoll and Pichler.t Where there is much nausea, with a 

* Hildebrand, loc. cit. 

t Darstellungsversuch der inMahren; 1805. Ausgebrocheuen Epidemi, Bruin, 
1807. 



TYPHUS. 187 

bitter taste, and an icterode appearance of the eyes, and the arterial 
reaction is not violent, some benefit no doubt may sometimes accrue 
from the use of a vomit. As a general rule, however, the employ- 
ment of emetics in the stage of excitement, more especially where 
the febrile reaction is considerable, cannot be regarded either as useful 
or proper. When the disease is complicated with internal local in- 
flammation, they are inadmissible. To this, however, peripneumonic 
inflammation forms an exception ; for in this variety of complicated 
typhus, an emetic, after a cautious abstraction of blood, will fre- 
quently procure much relief. Armstrong seems to prefer antimonial 
emetics, but this article is apt to irritate the bowels, and to give rise 
to watery and exhausting alvine discharges. A large dose of ipe- 
cacuanha is not so liable to this objection, and experience would 
seem to show that, in other respects, it is quite equal to the antimony 
in this disease. To assist the emetic in exciting the action of the 
cutaneous exhalents in the chilly stage of the disease, the free use 
of some mild diaphoretic infusion should be enjoined, such as teas 
made of the eupatorium perfoliatum, balm, elder-blossom, catnip, &c. 

Although active purging anterior to the stage of excitement can 
rarely be proper, from its tendency to promote the centripetal direc- 
tion of excitement and the blood, yet mild laxatives ought to be 
among the first remedial measures. Calomel in large doses, from 
ten to fifteen grains, generally answers this purpose well; its usual 
evacuant effect being two or three copious feculent discharges, with 
the additional advantage of exciting the regular action of the liver. 

Gentle purgatives are, indeed, among our most useful remedies 
throughout the whole course of the disease. " The full operation 
of aperients in this disease," says Armstrong, " sometimes reduces 
the morbid heat of the skin, and the morbid force of the pulse in the 
stage of excitement, almost as effectually as the affusion of cold water 
or venesection." 

In the commencement of the fever, it will, in general, be proper 
to exhibit an active purgative, so as to procure free evacuations. 
Subsequently, however, it will be sufficient to procure two or three 
moderate stools daily, by means of suitable laxatives or enemata. 
Calomel followed by a small dose of castor oil, usually answers this 
purpose very well. Four or five grains of calomel, with a grain of 
ipecacuanha, may be taken late in the evening, and half an ounce 
of castor oil on the following morning. 

Even in the state of collapse, purgation sometimes becomes essen- 
tial to the successful issue of the case. In this, as in other low 
forms of fever, the brain and the whole system are sometimes greatly 
oppressed by intestinal irritation from acrid and offensive recremen- 
titious matters poured into the alimentary canal, and this is particu- 
larly apt to occur in the advanced periods of the disease. In such 
instances, the prostration is very great, the face flushed, the pulse 
frequent and irregular, or slow and feeble; the eyes fixed and red, 
with coma, delirium, or a kind of stunned torpor of the intellectual 
and sensorial functions. In cases of this kind, a spontaneous dis- 
charge from the bowels, of a dark, or black, and highly offensive 



188 TYPHUS. 

matter, or the free operation of a purge, will frequently almost 
immediately improve the whole aspect of the disease. (Armstrong.) 
I have, in several instances, seen patients almost entirely insensible, 
and in a state of extreme prostration in the latter stage of typhus, 
speedily restored to consciousness, and a general improved state of 
feeling and strength, by the copious discharge of dark offensive matter 
from the bowels, in consequence of the exhibition of a purge. This 
oppressed state of the system from intestinal irritation, is especially 
apt to occur where proper laxatives have been neglected in the 
commencement of the disease, or where early spontaneous diarrhoea 
has been incautiously arrested by medicine. When purgatives are 
deemed proper during the collapse, they should be given in conjunc- 
tion with stimulants, particularly wine, or the carbonate of ammonia, 
in a mucilaginous solution. From eight to ten grains of calomel, 
followed by the occasional use of a tablespoonful of senna, or of a 
solution of Epsom salts, assisted with stimulating enemata, usually 
answers well in such cases. I have given castor oil with spirit of 
turpentine, with the happiest effect during the collapse.* We may 
frequently, also, obtain a free evacuation of the bowels, by the 
external application of croton oil to the abdomen. Four or five 
drops of this oil, with a teaspoonful of sweet oil, should be rubbed 
in on the epigastrium. I have in several instances procured copious 
discharges from the bowels, in the course of a few hours, by this 
application; and I am satisfied that it will seldom fail of producing 
this effect. 

Perhaps the most important remedy in the early period of typhus, 
with the view of arresting its progress, or moderating its violence, 
is mercury. In the simple variety of the disease, 1 have known its 
course effectually interrupted by a gentle mercurial treatment during 
the forming and early period of the stage of excitement. If the 
system can be brought under the mercurial influence durins; this 
period, it will often put a speedy stop to its progress. The plan 
recommended by Drs. Tully and Minor,t for the exhibition of mer- 
curials in this disease, deserves, I think, the preference. It consists 
in the administration of small doses of calomel, from one to two 
grains every three or four hours, until slight manifestations of its 
specific influence occur in the mouth of the patient. If this quan- 
tity acts too powerfully on the bowels, a few grains of Dover's 
powder should be added, so as to restrain, but not wholly suppress 
its effects in this respect. Dr. Rush states, that he has known the 
pulse to become full, and an evident amendment to ensue on the 
supervention of a gentle salivation. Dr. Warren,^ of Boston, also 
testifies to the good effect of mercury in typhus fevers. Among the 
German physicians, Brandis, A. G. Hecker, Sauter, and Goeden, 

* R.— 01. Ricini, 3i. 

Spir. terebinth, ^ii. — M. ft. To be taken in divided doses in the course 
of an hour. 

t Treatise on Fever. 

% The Mercurial Treatment of Fever. 



TYPHUS. 1S9 

speak with decided approbation of the employment of calomel in 
this disease, with a view of its constitutional operation. Hildebrand, 
on the contrary, declares that he has never known this remedy to do 
any good, but often harm. 

With regard to the employment of venesection in typhus, much 
difference of opinion exists among physicians. In the simple form 
of the disease, it will seldom be necessary to employ the lancet; but in 
cases where the arterial reaction is strong in the onset of this stage, 
the cautious abstraction of blood will often be useful. Of late years 
the practice of bleeding, even in simple typhus, has been warmly re- 
commended by many practitioners of enlarged experience. Dr. Mills 
states, that of 9195 typhus patients received into the Dublin Hospital, 
and who were chiefly treated by blood-letting, 740 died, making the 
proportion of deaths nearly 1 to 11. He further states, that out of 91 
patients in St, George's Dispensary, who were bled, only 1 out of 25 
died ; and in another place he states, that of 504 typhus patients who 
were bled, he lost but 1 out of 28. 

Against these statements we may quote the experience of Dr. 
Stocker. This very respectable physician has shown from Hospital 
documents that the success of other practitioners who did not bleed in 
this disease was greater than that of Dr. Mills, they having lost but 
1 out of 12 ; and Dr. Stocker, in private practice, lost only 1 out of 96. 
It must be confessed, that comparative estimates of this kind are liable 
to many objections. One thing, however, seems to be conclusively 
estabUshed by these statements — namely, that blood-letting in typhus, 
under judicious management, is by no means so dangerous a practice 
as was formerly, and indeed is yet by many supposed. As a general 
rule, blood-letting must be regarded as unnecessary, and often inju- 
rious in the simple variety of the disease ; but cases, even of simple 
typhus, do occur, in which this evacuation may be very beneficially 
practised. The j ndicious practitioner can seldom fail to perceive when 
blood-letting is likely to do good. When the pulse is active, quick, 
and strong, or full and considerably resisting, as is sometimes the case, 
blood ought unquestionably to be drawn. We must, nevertheless, not 
forget, in the use of this remedy, that typhus is a disease attended 
with a radical tendency to prostration ; a consideration which will 
be a sufficient caution to the judicious practitioner to proceed with 
much circumspection in the use of the lancet, even in cases which 
most clearly indicate the propriety of the measure. 

Another very important remedy in the stage of excitement of typhus 
is the affusion of cold water. When employed whilst the skin is hot 
and dry, and the arterial excitement considerable, cold aff'usions often 
procure great relief, and sometimes give a speedy tendency to con- 
valescence.* A feeling of chilliness, or a temperature of the skin 
below the natural standard, or a moist skin, decidedly contra-indicate 
the use of this remedy. Under opposite circumstances, however, that 
is, when the skin is dry, and elevated in temperature, no remedial 
measure is more grateful to the feelings of the patient, or more apt to 

* Medical Reports, by Dr. James Currie. Dr. N. Smith, Essay on Typhus. 



190 TYPHUS. 

mitigate his sufferings. According to Armstrong, cold affusions are 
rarely beneficial after the fourth day of the stage of excitement ; after 
this period, /e;;z^ affusions, of the temperature of about 95°, he says, 
ought to be used. In general this may be correct, but where the sur- 
face is dry, and above the ordinary degree of heat, we may safely 
and beneficially use affusions at a considerably lower temperature. 
When the heat of the surface is unequally distributed, ;?ar/m/ ablu- 
tions of the hands or feet will sometimes have a favourable effect. The 
existence of visceral inflammation forms an objection to the use of 
this remedy. After the heat of the skin has been reduced by the 
affusion of cold water, the patient should be dried and laid between 
two blankets, and warm diaphoretic tisans administered — such as 
catnip, balm, or sage tea. When the brain is much affected, we" 
should place the feet in warm water while the cold water is upon the 
head and over the body. (Armstrong.) 

Diaphoretic remedies, such as the spiritus mindereri, the saline ef- 
fervescing draught, spirit, nit. dulc. with vin. antimonii and laudanum, 
may be employed as auxiliaries to the more efficient means already 
indicated in the stage of excitement.* Active sudorifics, however, 
are rarely admissible. A cuf) of the elder blossom tea, with twenty 
or thirty drops of the sweet spirits of nitre, may be given every two or 
three hours during the stage of arterial reaction. In cases attended 
with considerable bronchial irritation and cough, Goeden recommends 
the use of muriate of ammonia in solution, with a large portion of 
mucilage, and the extract of liquorice to disguise its disagreeable 
taste. t 

When the stage of collapse has supervened, the plan of treatment 
must be exciting and roborant. In the employment of stimulants, 
however, much caution and circumspection must be used, lest latent 
inflammations be roused by over-stimulation. In some instances, the 
tendency to visceral inflammation is kept down by the antiphlogistic 
measures used in the preceding stage ; but no sooner are stimulants 
given on the occurrence of collapse, than violent delirium ensues, 
the eyes becoming red and filmy, the face flushed, in short, unequi- 
vocal symptons of cerebral inflammation coming on. (Armstrong.) 
Should the delirium, therefore, become more violent, the skin dry 
and very hot, and the pulse more frequent and corded, on the ex- 
hibition of stimulants, we must either omit their further use, or 
employ only the milder articles of this kind. When the sensorial dis- 

* R. — Spir. mindereri gvij. — Liquor Amraonise Acetati. 

Vin. antimon. ^iss. 

Spirit, nitr. dulc. gij. 

Tinct. opii, gtt. 45. 

Syrup limonis ^ij.— M. Dose, a tablespoonful every two hours, 
t R. — Muriat. Ammon. §iss. 

P. g. ATab. 3ij. 

Extract. Glycyrrh. ^iij. 

Spirit. Nit. Dulc. giss. 

Acid. Scillaj giii. — M. Dose, a tablespoonful every two hours. 



TYPHUS. 191 

turbances are moderated, or not increased, and the pulse becomes 
slower, and somewhat softer and fuller, and the skin less acrid and 
hot, on the exhibition of stimulants, we may proceed with confidence 
in their employment. It is best always to begin with the weaker 
stimulants when the period for their use has arrived. Hildebrand 
speaks in very favourable terras of the rad. contrayerva, and par- 
ticularly of the angelica. When the collapse is not great, these and 
olher analogous articles may often suffice, but in instances of great 
prostration and sinking we must resort to much more potent excit- 
ants. IVine is an excellent stimulant in the collapse of fevers. The 
white wines are the best, and of these Madeira is perhaps the prefera- 
ble one. The carbonate of ammonia also is much employed in this 
country in the low states of fever. From its diaphoretic tendency, it 
may in general be administered much earlier on the supervention of 
collapse than wine, for instead of increasing the heat and dryness of 
the skin, an effect not unfrequently the consequence of the adminis- 
tration of wine, it generally causes a softness of the surface, and a 
freer and less irritated action of the heart and arteries. It must be 
given in solution, mixed with a large portion of mucilag. Thus : 
K. — Carbonatis arrlmon. ^ij. 

Pulv. g. arab. 5iij. 

Sacch. albi, gss. 

Aq. fontanae §yiij. 

Tinct. opii, gtt. 40. — M. ft. S. A tablespoonful every hour or two. 

In extreme cases, wine and the carbonate of ammonia may be 
given conjointly with advantage. Indeed, when we consider that 
ammonia has a tendency to counteract the inebriating effects of alco- 
holic liquors, we have reason to suppose that the union of these two 
articles is peculiarly apropriate as a stimulant in this disease.* Cam- 
phor has been long celebrated as a stimulant in cases of low fever 
w ith much functional disorder of the brain. The Germans, especially, 
place great reliance on its use, in instances of this kind. Hildebrand 
asserts, that in the collapse of typhus, it is one of our most valuable 
remedies. Its power of moderating sensorial disturbances— particu- 
larly delirium, is often more decisively manifested in this disease than 
that of any other remedy we possess. I have myself had repeated 
evidence of its virtues in this respect, and am inclined to think that it is 
not sufficiently estimated by the profession in this country. Camphor 
may be very conveniently given in the form of solution in sulphuric 
ether. Thirty or forty drops of a solution of two drachms of camphor 
to an ounce of ether,' may be given every hour or two. Perhaps the 
best way, however, of administering this article, is in the form of a 
mixture — thus : 

B- — Pulv. camphorsB, ^ij. 

G. arab. giij. 

Aq. fontanae, ^viij. 

Liq. anod. Hotf. gij. — M. ft. S. A tablespoonful every two or three hours. 

[* The late Dr. Kuhn is reported to have said, that he had seen more lives saved 
under desperate circumstances by Carb. Ammonia and wine whey, than by all 
other remedies whatsoever. — Mc] 



192 TYPHUS. 

Musk, also, has been much praised as a stimulant in the collapse 
of typhus. Where symptoms of nervous excitement are conspicu- 
ous, such as subsultus tendinum, tremors, hiccough, delirium, with 
a copious, pale urine, it will no doubt often do considerable good. 
In this country, however, we seldom get the genuine article, and as 
good musk is very expensive, and not upon the whole more efficient 
than the articles already mentioned, it is not often used by American 
practitioners. 

Opium was formerly a good deal employed in the advanced stage 
of this disease. Sydenham speaks favourably of its powers, and 
CuUen thought it valuable for allaying the low delirium in the col- 
lapse of the disease. In that oppressed state of the system which is 
sometimes caused by intestinal irritation in the latter period of typhus 
and typhoid diseases— and which is characterized by much jactita- 
tion, flushed face, stupor, or partial coma, with a very small flutter- 
ing pulse, I have known opium to procure great relief, especially 
after the operation of a purgative. In general, however, opium is of 
very doubtful efficacy in this disease — more especially where there 
is reason to apprehend much cerebral congestion or an approach to 
inflammation. In all instances, however, where great prostration is 
attended with much general nervous irritability and sympathetic 
cerebral disturbance, opium is a valuable remedy; but where the 
sensorial and nervous energies are torpid, as they almost always 
are in genuine typhus, its eff'ects must be, generally, mischievous. 
When profuse and exhausting diarrhoea occurs, or dysenteric symp- 
toms, opium with minute portions of calomel will often do much 
service. In such cases, I have used small doses of Dover's powders; 
three grains every two hours, with decided benefit. 

Phosphorus is a most potent stimulus ; but its tendency to excite 
mucous inflammation renders it a hazardous remedy in a disease 
which is so prone to gastro-enteritic inflammation. It is but seldom 
used. 

The flowers of the arnica montana is a favourite remedy in this 
disease with the German physicians. Collin, (Annus Med. Coutin), 
Stoll and Hildebrand, declare that they have used it with marked 
benefit in the collapse of typhus. It is said to moderate the sensorial 
torpor and delirium of the disease more certainly and safely than 
any other remedy we possess. It is given in infusion, in the pro- 
portion of one ounce to a pint of water, of which a tablespoonful is 
exhibited every hour. Goeden asserts that the arnica has a specific 
tendency to act upon the brain. 

Tonics do not possess much power in counteracting the prostration 
in the collapse of this disease. Their operation is much too slow to 
afford sufficient support where the vital powers are so rapidly sink- 
ing. In this observation we ought, perhaps, to except {he sulphate 
of quinine ; for it can scarcely be doubted that the liberal use of 
this potent tonic would frequently contribute promptly, and very 
efficiently, to the support of the vital energies. Given in doses of 
from four to six grains every hour or two/it could scarcely fail of 



TYPHUS. 193 

elevating and sustaining the actions of the system, where sufficient 
excitability remained to the impression of such remedies. 

Blisters are very variously estimated as Remedial . agents in 
typhus. Applied about the period when the stage of collapse is 
approaching, that is, about the seventh or eighth day of the fever, 
they sometimes exert a very beneficial influence on the disease. At 
an earlier period they are apt to increase the general irritation of 
the system; and at a more advanced stage, vesication tends to in- 
crease the exhaustion, and there is much danger from gangrene of 
the blistered surface. When applied at the proper time, blisters 
will often improve the state of the skin, and tend to remove irregular 
determinations of the blood. Applied to the back of the neck, they 
generally moderate the cerebral disturbance, more especially where 
meningeal inflammation is present. It is not necessary, nor in general 
proper, to suffer the vesicatory to remain on the skin until vesication 
is produced. When the skin is red, which will generally occur in 
the course of five or six hours, the plaster should be removed, and 
an emollient poultice applied in its stead. This will rarely fail to 
raise a blister in a few hours. 

During the collapse, or while the patient is delirious, frequent 
attention should be paid to the state of the bladder. Not unfre- 
quently the urine is retained until the bladder is greatly distended — 
an occurrence which cannot fail to add to the distress of the patient, 
and aggravate the general nervous and vascular irritation. When 
there is reason to suspect the existence of this condition of the bladder, 
immediate recourse ought to be had to the catheter.* 

What has been hitherto said, applies especially to the simple form 
of the disease ; and it remains for me to speak of the modifications 
of treatment proper, when visceral inflammation, or violent internal 
congestions, attend the malady. 

In cases of itjflammatory typhus, the antiphlogistic remedies must 
be promptly and efficiently urged. Blood-letting is here our main 
stay ; but in order that it may prove beneficial it must be employed 
soon after the supervention of the inflammation. " If it be delayed 
to the second or third day of the inflammation, it can no longer be 
employed without risk of irreparable injury." As a general rule, 
bleeding is seldom proper after the first twenty-four hours from 
the commencement of the inflammation : for the stage of collapse is 
apt to supervene rapidly on the occurrence of inflammation in this 
disease. (Armstrong.) It is always best to take away as much 
blood at once as will make a decided impression on the system. Dr. 
Armstrong advises that the blood should be suffered to flow until 
an approach of syncope is induced, and to eflfect this with as little 
expenditure of the blood as possible, the patient should be supported 

* [During the malignant tj-phus which prevailed in the Philadelphia Alms 
House, in 1817 — 18, a post-mortem examination revealed an over-distended bladder, 
in every fatal case, until the catheter was resorted to as a palliative remedy. In 
several cases this resort gave immediate relief to the coma and delirium, and 
enabled stimuli and nutriment to restore the strength. — Mc] 
VOL. I. — 13 



194 TYPHUS. 

in an erect or sitting position, while tlie blood is flowing. It is not 
necessary, generally, to take away much blood in typhus to produce 
an adequate effect. Unless a decisive impression be made on the 
system, however, little or no benefit will result from this measure. 
Topical bleeding by leeches or cupping, especially when the inflam- 
mation is seated in the abdomen, is also an important means for 
subduing the phlogistic character of the disease. Too much danger 
is apprehended, by many physicians, from blood-letting in inflam- 
matory typhus. It cannot, indeed, be pretended that the use of the 
lancet is without risk in an unskilful hand; but it may be confidently 
maintained, that in cases attended with visceral inflammation, blood 
may be abstracted both by venesection and leeches, not only without 
mischief, but with the greatest advantage, provided it be early prac- 
tised, and under the guidance of a judicious estimate of the powers 
of the system, and the exigencies of the case. When the inflam- 
mation is seated in the brain, much good is often to be obtained 
from the application of cold water or ice to the head. In instances 
complicated with pulmonic inflammation, calomel and opium, afUr 
blood-letting has been performed, is a remedy of excellent powers. 
A grain of each may be given every three or four hours. In the 
typhus pneumonia, which was so prevalent in this country in 1812, 
I employed this remedy in a number of cases, and frequently with 
marked advantage. Indeed, when we advert to the fact, that these 
two articles, in combination, have been highly extolled by many 
very eminent writers,* in inflammation of the lungs, attended with 
a high grade of vascular actioa, we can scarcely doubt of their appli- 
cability in pneumonia, when .connected with fever of a low grade 
of exciternent. The pain and distress caused by the inflammation, 
generally soon abate considerably under the influence of this remedy; 
the skin often becomes moist and cooler, and the pulse more expanded, 
and less frequent. It must be recollected, however, that where there 
are symptoms indicative of cerebral inflammation, opium is wholly 
out of the question. It is particularly in pneumonic inflammation 
that the combination of calomel and opium is valuable ; and much 
benefit may also be sometimes obtained from it in abdominal in- 
flammations. 

In leaving this subject, it may be proper to remark, that typhus 
fever, whether simple or inflammatory, is always attended with a 
radical tendency to prostration. The pulse may at first be full and 
active, yet the vital powers are essentially, and ab initio, debilitated 
by the influence of the remote cause of the disease. This declara- 
tion does not contradict the recommendation of antiphlogistic means 
in the stage of excitement. Radical debility and inflammatory action 
are by no means incompatible : nor need we apprehend danger from a 
judicious employment of antiphlogistics, where much general vascular 
irritation is associated with debility of the vital energies. Neverthe- 
less, the practitioner should not forget, that whilst he is employing 
such measures, there is lurking at the bottom a tendency to ultimate 

* Armstrong, Hamilton, Schraidtman. 



TYPHUS. 195 

prostration and exhaustion. With this precautionary view of the 
general character of the disease, he will always proceed with due 
care in the use of depletory measures, and keep a watchful look out 
lest the patient be incautiously precipitated into a fatal state of ex- 
haustion. 

In the congestive modification of typhus, Dr. Armstrong recom- 
mends blood-letting as the most efficient means for relieving the heart 
and internal organs from the overwhelming load of blood, and re- 
exciting the oppressed action of the heart and arteries. 

As the internal congestions, however, appear to be the consequence 
of a previous loss of energy in the vital powers, and especially of the 
extreme vessels, it would seem most efficient and prudent to endea- 
vour to remove this condition by means calculated to impart warmth 
and vigour to the system, and to recall the circulation to the extreme 
vessels of the surface. The means best calculated to effect these salu- 
tary changes, are stimulating frictions and warm applications to the 
external surface. Bottles filled with hot water, applied to different 
parts of the body, and frictions with tincture of capsicum, or flannels 
wrung out of hot brandy, are among the most effectual means for 
exciting the action of the extreme vessels, and deriving the circula- 
tion from the internal organs. Measures of this kind possess the pe- 
culiar advantage, in the congestive forms of fever, of exciting the 
energies of the system instead of diminishing its resources, at the same 
time that they most efficiently tend to equalize the circulation and 
remove the congestion. It should be recollected, that typhus is a dis- 
ease of debility — that the powers of life are weakened irom its com- 
mencement—and that, consequently, that mode of treatment is best 
which answers the purpose in view with the least expenditure of the 
resources of the system. Most assuredly, therefore, the removal of 
internal congestions by a gradual and invigorating excitement com- 
municated to the nerves and capillaries of the surface of the body, 
must be much more safe than the attempt to accomplish the same 
purpose by abstracting blood from the patient, which, though per- 
haps adequate to remove the congestion, may readily convert appa- 
rent into real weakness. That the external and internal exciting 
measures just mentioned are, in truth, more efficient for removing the 
congestive states of fever than direct depletion, may b6'inferred from 
the observations of Dr. Armstrong himself. " When, after bleeding," 
he says, "the pulse still remains oppressed, and the tide of circulation 
does not return to the surface, some wine with warrii- water should 
be occasionally exhibited, and the patient speedily immersed in a bath 
strongly impregnated with salt, and about the temperature of 100° of 
Fahrenheit. On leaving the bath, the patient should be well rubbed 
all over with hot flannels, and then laid in an aired bed with bottles 
of warm water applied to his feet. This plan will often promote the 
flow of blood to the surface." Now, if even in the most aggravated 
cases of congestive fever, the internal exhibition of wine, with warm 
and stimulating applications to the surface, will determine the blood 
to the extreme vessels, and remove the oppressive internal congestion, 
we may conclude ci fortiori, that in the mildey distances of the con- 



196 TYPHUS. 

gestive state, this exciting plan of treatment will be still more apt to 
recall the blood to the surface and equalize the circulation. 

. In addition to the above means for overcoming oppression from 
internal congestions, blisters, large doses of calomel, and purgatives, 
are important remedies. The bowels should be freely evacuated as 
^oon as the reaction of the heart and arteries is in some degree re- 
established. Calomel in large doses appears to be peculiarly adapted 
to cases of this kind. From ten to twenty grains must be given every 
three or four hours until the bowels are moved, and its operation pro- 
moted by stimulating enemata. Dr. Armstrong observes, that " the 
power of equalizing the circulation is nowhere more conspicuously 
displayed than in diseases of a congestive character. Before the 
exhibition of it the skin will be warm and shrunk, the pulse feeble 
and oppressed, and the whole system apparently relaxed ; but no 
sooner is the mouth made sore by its specific influence, than the skin 
becomes warm, reddish, and distended with the invigorated circula- 
tion, while the pulse is full, soft and strong, and the general energy 
in a great measure restored." My own experience accords fully with 
these observations. At the same time that calomel is given with the 
twofold object of procuring its purgative and constitutional influence, 
active; rubefacients or sinapisms may be advantageously applied to 
the epigastrium. (Armstrong.) The congestive form of typhus often 
terminates fatally in a few days, and is always rapid in its course. 
Our remedies must, therefore, be promptly and diligently applied in 
cases of this kind. After the reaction has been established, the same 
general plan of treatment applicable to simple typhus must be pur- 
sued. 

With regard to the dietetic management of this disease, it is scarcely 
necessary to state that the simplest kinds of liquid nourishment are 
alone admissible. Of these, however, the patient may be allowed as 
much as he can be induced to take, more especially during the sink- 
ing stage of the complaint. By keeping the stomach and bowels 
moderately distended with bland liquids, considerable support is given 
to the sinking powers of the system, and good, moreover, probably 
arises from it by its tendency to allay intestinal irritation, and afford- 
ing the absorbents a supply of mild and invigorating fluid for the 
support of the system. Dr. Stoker states, that in the late epidemic 
typhus of Ireland, many of the patients who were brought into the 
Dublin Hospital, began to recover almost immediately on being 
allowed the free enjoyment of mild nutritious fluids. Dr. Samuel 
Colhoun, of this city, adopted a similar plan of treatment in the 
Pennsylvania Hospital, some years ago, and the result was entirely 
favourable.^ 

During convalescence, tonics in moderate doses, such as the infu- 
sions of cinchona, serpentaria, chamomile, slightly acidulated with sul- 
phuric or nitric acid, may in general be employed with advantage. 
The diet during this period should be mild, digestible, and nourishing, 
and particular care must be taken not to oppress the stomach by 

* See his essay on this subject, in the fourth volume of the JNIedical Recorder. 



TYPHUS, 197 

taking more food at a time than can be easily digested. Weak wine 
and water may be taken occasionally.* 

* [Of late very respectable attempts have been made to separate the cases of 
continued fevers which occur in Europe and this country into two distinct species 
or forms ; — one of which is called typhus, and the other typhoid or ileo-typhus. 
Among those who have written most elaborately and classically upon this subject 
is Professor Bartlett, now of the Maryland Universit3^ Dr. Gerhard, of this city, 
has also published many excellent observations in elucidation of this subject and 
in confirmation of the views of Louis. The typhus prevails in London, the tj-- 
phoid in Paris. The latter is, according to. Dr. Gerhard, the most common form 
of continued fever in this country. In typhus there is more congestion in the 
brain and substance of the lungs — hence it has been donominated by some hron- 
cho-typhus. In this form there is more stupor, which begins earlier and is present 
in every case. Delirium and subsultus are almost invariably present. The skin, 
if there be any power of reaction, is always hot and burning. The pulse, rapid 
and variable: often undulating. The tongue dry and black, the fetor intolerable. 
In typhoid fever there are less stupor, delirium and subsultus — indeed, these symp- 
toms are often absent. The tongue is less darkly furred than in tj^hus — this con- 
sisting generally of a white fur until the later stage. The pulse is less frequent 
and more steady. The skin less hot — often moist and perspiring throughout 
the whole progress of the disease. The eruptions in tj^hoid fever are confined 
mainly to the abdomen, and do not extend over the whole surface as in typhus. 
In fact, typhus has been regarded as a really exanthematous di.>ease in conse- 
quence of a universal eruption of petechiaj, which generally appears about the 
fourth day, and but partially disappears on pressure. 

The averfige duration of typhus is less, and death often takes place earlier than 
in typhoid fever. The most striking of the post-mortem appearances in typhus is 
that of congestion or engorgement in the lungs, and also in the brain. The blood 
is dark-coloured, and often fluid or dissolved. But there is no real anatomical 
character in typhus, such as prevails, according to Louis, in all cases of typhoid 
fever. There are well-marked lesions of the alimentary canal and of the spleen. 
The spleen enlarges and softens remarkably, but gradually recovers its natural 
condition in case the patient gets well. The true anatomical character of this dis- 
ease, however, is an inflammation, enlargement, and finally ulceration of the con- 
glomerate glands of Peyer, above the termination of the small intestines, near 
the ileo-colic valve. The follicles of Bruner are sometimes also affected, and the 
same appearance extends down some distance into the colon. The mesenteric 
ganglia are also often inflamed and softened in connection with the intestinal fol- 
licles Avith which they are associated by the lacteals. If the patient recovers, the 
ulcers gradually cicatrize, and the enlargement of the mesenteric glands disap- 
pears. In the meanwhile, however, the patient is subject to a diarrhcea and tym- 
panitic distension, and occasionally to bloody evacuations. 

The English physicians do not, as yet, appear to have given in their adhesion 
to the doctrine of Louis, but generally regard these organic lesions as accidental 
complications — not essential to the character of any disease. In this country, 
however, a large portion of the profession consider them as peculiar and essential — 
bearing the same relation to typhoid fever as the pustules of small-pox maintain 
with the febrile symptoms of that contagion. — Mc] 



198 INFLAMMATION IN GENERAL. 



II.-GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS, CON- 
NECTED WITH, OR DEPENDENT ON, LOCAL INFLAMMATION. 



CHAPTER IX. 

OF INFLAMMATION IN GENERAL. 

Preliminary to considering the general affections which properly 
belong to this head, it will be necessary to treat of the phenomena, 
nature, and progress of inflammation. The scope of this work does 
not admit of a full discussion of this interesting subject, but it is be- 
heved that the following summary will be found to embrace all that 
is really important or well established in relation to this form of vas- 
cular disease. 

Although inflam,niation is characterized hy pain, increased heat, 
redness and swelling, yet none of these phenomena are to be regarded 
as strictly essential to its existence. Each of these phenomena, too, 
is greatly diversified in its character, according to the nature of the 
structure in which the inflammation is located. Thus /?a/w, though 
generally present, is not always so, and it would seem that the looser 
the structure, the less violent in general will be the sensation of pain. 
Inflammation of the lungs, of the mucous membrane of the stomach 
and bowels, of the brain,* and of the pericardium, has been found 
from the commencement, to its termination in death, entirely unat- 
tended with pain. Even the character of the pain is modified by 
the nature of the inflamed structure. In the mucous membranes it 
is burning or stinging ; in the pleura it is lancinating and generally 
extremely acute ; in the ligaments, or fibrous structures, it is dull, 
aching, and gnawing ; and in the nerves rapid, darting, and excruciat- 
ingly severe. But although the pain may sometimes be very trifling 
or even absent in inflammation, a feeling of soreness or aggravation 
on pressure always occurs. In this, inflammatory pain differs essen- 
tially from the pain which attends spasm. 

The violence of the sympathetic febrile reaction is in general pro- 
portionate to the intensity of the pain experienced in an inflamed 
part. Thus, in acute bronchitis, or peripneumonia notha, there is 
neither very severe pain nor very vigorous reaction of the heart and 
arteries ; whereas, in inflammation of the pleura, both the pain and 
the febrile reaction are almost always extremely great. 

Increased heat is another general phenomenon of inflammation 
which is sometimes absent. The sensation of heat in an inflamed 

* Med. Chir. Rev., Jan. 1827, p. 234. 



INFLAMMATION IN GENERAL. 199 

part does not appear to depend on any actual accumulation or ele- 
vation of temperature measurable by the thermometer, but on the 
altered state of the sensibility of the nerves implicated in the inflam- 
mation ; for the sensible heat of an inflamed part rarely indicates 
more than 90° of Fahrenheit's thermometer.* 

The most invariable phenomenon of inflammation is redness. It 
arises from the passage of red blood into the serous capillaries, which 
either from del)ility, and consequent relaxation, or from an altered 
state of their specific sensibility, offer no resistance to the intromis- 
sion of the red globules of the blood. This redness generally remains 
after death, and affords one of the ordinary post-mortem evidences of 
inflammation. Redness, by itself, however, cannot be regarded as a 
certain sign of previous inflammation, for the serous capillaries may 
become injected with red blood in articulo mortis, although wholly 
free from previous disorder. I have already adverted to this fact, 
and to the erroneous inferences it may lead to, in the preliminary 
chapter on the pathology of fever. 

Swellinsc is always more or less present in the soft structures, and 
appears to depend on eff'usion of serum into the surrounding cellular 
tissue, and on the dilatation of the capillary vessels. The firmer the 
structure is, the less swelling will occur from inflammation. 

Inflammation is an affection of the capillary system of vessels, and 
appears to consist of an altered condition of their vital properties, 
with inordinate sanguineous congestion, and hence the more abun- 
dant the capillaries of a part are, the more apt it is to become in- 
flamed. The mucous, serous, cellular and dermoid structures being 
peculiarly vascular, are much more frequently affected with inflam- 
mation than the osseous, cartilaginous and tendinous structures. — 
(Bichat.) 

Inflammation may be produced, 1. By the direct operation of irri- 
tating causes on the animal structure; as wounds, bruises, burns, 
mustard, cantharides, turpentine, the acids, or various caustic sub- 
stances. 2. By the indirect operation of irritants, through the me- 
dium of the nervous system. Thus, acid in the stomach will some- 
times give rise to superficial cuticular inflammation ; and meningeal 
inflammation is frequently the consequence of irritants acting on the 
mucous membrane of the intestinal canal. 3. By general increased 
action of the heart and arteries, as frequently occurs in synochal 
fever, where any portion of the capillary system is accidentally debi- 
litated, and thereby predisposed to inflammation. It is in this way 
that most of the inflammations which occur in fevers arise, for when 
the momentum of the general circulation is augmented by the in- 
creased action of the heart and arteries, the blood will, by its impe- 
tus, be forced into those capillaries which, from debility, either acci- 
dental or induced by the remote febrific cause, offer less resistance to 
its intromission than they do in a state of natural vigour. 4. By 
metastasis ; thus, erysipelas sometimes passes in and fixes upon an 
internal organ ; and gout occasionally passes from the feet to the slo- 
mach, brain, and to various other parts. 

* Hunter on the Blood. 



200 INFLAMMATION IN GENERAL. 

Whatever may be the remote existing cause of inflammation, it is 
probable that the following changes are effected in the progress ot 
its evolution. 1. Irritation, that is, a certain inordinate or hurtliil 
impression on the nervous filaments of the part, by which a new and 
irregular excitement is produced in them, called irritation. 2. Alter- 
ation of the vital properties of the capillaries of the part thus irri- 
tated or disturbed by the unnatural impression ; and 3. An afliux, or 
determination of the blood to these capillaries. (Bichat.) These 
changes often succeed each other so rapidly, that they seem to occur 
simultaneously. A change in the sensibility and irritability of the 
capillaries, would seem to be essential to the existence of inflamma- 
tion; for where these vital properties remain in their normal state, 
preternatural determination of the blood into them does not constitute 
inflammation, but only congestion, or local plethora.* 

Are the capillaries of an inflamed part in a state of debility and 
passive relaxation, and is the velocity of the blood circulating in 
them diminished, as is contended by Vacca, Lubbeck, Allan, Philip, 
and Hastings ; or, are these vessels in a state of increased action, 
and the momentum of the blood within them augmented, as is main- 
tained by Hunter ? Upon these points, there has been a great deal 
written both pro and con, and the subject is still not well settled. 
My own view on this subject is, that the inflamed capillaries ought 
to be regarded as being in a state of irritation, and that this irritation 
may be connected either with an increased or decreased power of 
action. In this respect, local inflammation corresponds with that 
general irritated vascular excitement which constitutes fever. The 
heart and arteries are in a state of irritation, tf;i7A increased power of 
acting in synocha. In typhus, there is also general vascular irrita- 
tion ; but it is connected with a fundamental debility of the vital 
powers. There is, therefore, according to my apprehension, a typhus 
and a synochal state of local inflammation ; and this corresponds 
with the results we obtain from remedial applications. May we 
not explain these different diatheses of inflammation by the greater 
or less degree of organic injury sustained by the nervous filaments 
of the inflamed capillaries ? When a part is irritated, so as to exalt 
the sensibility of the capillaries, by pxciting their nervous texture, the 
consequent inflammation will probably be one of zncrea^e^ capillary 
action, and demand sedatives for its cure ; when, on the contrary, 
the irritating cause acts with such violence as to cause structural 
lesion in the nervous extremities, or when from the long continuance 
of the inflammation, the capillaries have in some degree lost their 
energies, the inflammation resulting from its action will be character- 
ized by debility, and demand stimulating applications, as is the case 
in scalds and burns. 

Terminations of inflammation. — Inflammation is said to termi- 
nate in resolution, when it declines, and disappears without having 
induced any structural lesion, or perceptible discharge. It consists 
in a gradual return of the vital properties of the inflamed part to 

* Bichat. General Anatomy. 



INFLAMMATION IN GENERAL. 201 

their natural condition, and a consequent resumption by the capil- 
laries of their ordinary or healthy action, before either some portion 
of the affected parts is destroyed from total loss of vitality, or 7ieiv 
secretions are formed by the morbid action of these vessels. Termi- 
nation by resolution is always more prompt in proportion as the 
inflamed part is endowed with a higher degree of vitality. (Bichat.) 
Frequently the termination of inflammation by resolution is accom- 
panied by an increase of the natural secretions of the affected organ ; 
and this is particularly noticed in the mucous membranes, as in 
catarrh and coryza, where an increased secretion of mucus always 
announces the favourable termination of the inflammation. The 
same fact is also conspicuously exemplified in rheumatic inflamma- 
tion, which rarely terminates without an increased exhalation of 
serum into the surrounding cellular structure. Effusion is another 
of the terminations of inflammation. The fluid effused may be 
either blood, or lymph, or serum. The termination by effusion of 
blood occurs most commonly from the softer and more vascular 
structures, more especially from the surface of mucous membranes. 
Lymph and serum are rarely effused from this structure, these effu- 
sions being almost peculiar to the serous membranes. The lymph 
which is thus effused in the declension of inflammation from serous 
membranes, often forms a bond of union, and causes firm adhesion 
between them when contiguous to each other. It is thus that the 
costal and pulmonic portions of the pleura are so frequently found 
united, in consequence of thoracic inflammation. In the mucous 
membranes, such adhesions never occur from inflammation ; and 
this is one of those wonderful adaptations in the animal economy, in 
which the benevolent design of an all-wise Providence is especially 
conspicuous ; for without this peculiarity in the mucous structures, 
we should be continually liable to the adhesions between the sur- 
faces of the various excretory ducts, as wefl as of those of the aliment- 
ary canal and respiratory passages, since these are more frequently 
affected with inflammation than any other parts of the animal system. 
When lymph is effused into the substance of the soUd viscera, or into 
the cavities of the cellular tissue, it causes a consolidatiou of these 
parts, forming what are technically called indurations. The spleen, 
liver, and lymphatic glands, are particularly liable to these conse- 
quences from inflammation. 

Suppuration, also, is one of the modes in which inflammation is 
wont to terminate. Of all the animal tissues, the mucous and cel- 
lular are most liable to this mode of termination. The bones and 
tendons never enter into the suppurative action from inflammation ; 
and the serous membranes, though liable to suppuration from in- 
flammation, are much more apt to pour out an increased flow of 
serous fluid. The product of the suppurative process differs con- 
spicuously in the different structures that are liable to it. In the 
mucous membranes, the fluid elaborated by this morbid action con- 
sists of a whitish, cream-like, or greenish appearance, denominated 
pus. In the serous membrane, the pus is formed by a kind of ex- 
lialation, and consists of a thin, ivhey-like fluid, generally intermixed 



202 INFLAMMATION IN GENERAL. 

with flakes of coagulated lymph. Suppuration of the celhilar tissue 
produces a thick pus, of a pale-yellow colour and uniform consistence, 
exhibiting, under the microscope, the appearance of minute globules 
suspended in a serous fluid. The grade of inflammation which 
results in suppuration, transcends that which is necessary for the se- 
cretion of lymph ; and hence, round the circumference of inflamed 
parts, involving cellular tissue, where the inflammation is less active 
than at the central portions, lymph, and not pus, is formed : in con- 
sequence of which, the cells adhere to each other around the internal 
suppurating space, and form a circumscribed cyst or cavity in which 
the pus is retained, constituting an abscess. The occurrence of sup- 
puration in an internal organ, is generally manifested by a sensation 
of weight in the region of the aflected part ; a change from an acute 
to a heavy, dull, and throbbing pain ; rigors ; a change from a hard, 
tense, and quick pulse, to a soft and moderately full one ; night 
sweats, and other symptoms of hectic. 

Inflammation may also terminate in gangrene. This mode of 
termination never occurs in the cartilages, nerves, and bones : the 
mucous, cellular, and serous tissues being most prone to it. Of the 
serous tissues, the peritoneum appears to be most apt to become 
gangrenous from inflammation ; and of the mucous membranes, that 
which lines the alimentary canal is most subject to this termination. 
The occurrence of gangrene is attended with a sudden cessation of 
pain; sinking of the pulse ; cold extremities ; cold sweat; indistinct- 
ness of vision ; slight delirium ; and a cadaverous expression of the 
countenance. 

The four modes in which inflammation terminates, appear to be 
determined by four corresponding grades of the inflammation. This 
is strikingly illustrated in the phenomena of common phlegmon or 
boil. Along the circumference, where the inflammation is weakest, 
there is serum effused into the surrounding cellular structure ; a little 
further towards the centre, where the inflammation is somewhat 
greater, lymph is thrown out, and adhesions formed; within this 
circle, where the inflammation is still more violent, pus is secreted; 
and at the central portions gangrene and sloughing occur. (Hunter.) 

The different forms of inflammation manifest different tendencies 
in relation to these terminations. In boil and whitlow, there is an 
especial tendency to suppuration ; in carbuncle, the disposition is to 
terminate in gangrene; and in rheumatism and mumps the tendency 
is strongly to resolution. Indeed, so strong are " these original dis- 
positions to terminate in one mode rather than another, that it is 
very difficult to procure any other termination than the one to which 
the tendency exists."* 

Inflammation occurs under five prominent modifications, corre- 
sponding to the five elementary tissues, viz.: the cellular, the serous, 
the mucous, the dermoid and the fibrous. 

1. Inflammation of the cellular tissue or phlegmonous inflamma- 

* Observations on the Nature and Treatment of Inflammation. By J H James, 
p. 17. 



INFLAMMATION IN GENERAL. 203 

tion is characterized by great swelling, throbbing pain, and by its 
peculiar mode of suppurating— the pus being collected in circum- 
scribed cavities. 

2. Inflammation of the serous structures, or serous inflammation, 
distinguished by very acute lancinating* pain ; little or no tume- 
faction ; much sympathetic reaction of the sanguiferous system; by 
its tendency to terminate in the exudation of coagulable lymph or 
serum, or the secretion of a thin, whey-like pus. It is peculiarly 
rapid in its course, and is not apt to terminate in gangrene. Ad- 
hesions are peculiar to this and the former modification of inflam- 
mation. 

3. Inflammation of the mucous tissues or mucous inflammation, 
is attended with a burning or stinging pain, without tumefaction of 
the subjacent cellular structure ; the sympathetic fever attending it 
is not vehement; and it never terminates in resolution, without an 
increase of the mucous secretion. 

4. Inflammation of the dermoid system, or erysipelatous inflam- 
mation, is attended with a burning pain; it spreads irregularly over 
the surface of the skin, forming vesicles or blisters, containing a 
transparent straw-coloured serum, and never forms adhesions, or 
suppurates in circumscribed cavities. This variety of inflammation 
generally depends on constitutional causes, and it would seem, in 
some instances, on a specific cause. 

5. Inflammation of the fibrous structure, or rheumatic inflamma- 
tion, is accompanied with intense aching or gnawing pain ; and is 
particularly indisposed to terminate in suppuration or gangrene — its 
almost universal termination being in the exudation of serum and 
a gelatinous fluid, or in the deposition of earthy matter. It is apt to 
change its situation from one place to another, and sometimes passes 
suddenly to the internal organs. The sympathetic fever which ac- 
companies its acute form is always very vigorous. This modifica- 
tion of inflammation rarely proves fatal, unless by metastasis to 
organs essential to life. 

The existence of internal inflammation is ascertained by the pain 
contiiming without much remission ; the appearances of the blood, 
which, when drawn, very generally exhibits a sizy or buffy crust on 
the crassamentum ; by the presence of fever, which does not attend 
spasmodic or nervous pain, by the effects oi external pressure, uioxe 
especially in abdominal inflammation— thus causing an aggravation 
of the pain, or a feeling of great soreness — whilst in spasmodic pain, 
a mitigation of the patient's sufferings is usually the consequence of 
pressure. The effects of position also throw light on the diagnosis 
of internal inflammation ; thus, in abdominal inflammation, the patient 
lies on his back, with the knees drawn up, and the head and shoulders 
raised, in order to obviate pressure from the tension of the abdominal 
muscles. The character of the functional derangement, moreover, 
will assist us in ascertaining the existence of internal visceral inflam- 

* [This is true of the pleura. In the peritoneum, however, there is generally 
an exquisite tenderness, — Mc] 



204 GLOSSITIS. 

mation; and, finally, the nature of the exciting causes will aid us in 
the diagnosis. 

Inflammation occurs under two principal varieties, in relation to 
the rapidity of its progress and the violence of its phenomena— 
namely, acute and chronic inflammation. The former is rapid in 
its course, and violent both in its local and symptomatic phenomena. 
The latter is generally, though not always, the consequence of the 
former, and is characterized by a slow progress, and much less mtens- 
ity in all its symptoms. In the serous membranes, chronic inflam- 
mation results either in the efl"usion of serum, giving rise to dropsical 
accumulations, or to a gradual change of structure, such as thicken- 
ing and induration, and frequently to the formation of miliary tuber- 
culous matter. In the mucous tissues, the usual consequences of 
this variety of inflammation are phthisis, diarrhcea, dyspepsia, and 
various other local and general affections; and in the solid viscera 
and glandular structures, induration, scirrhus, and other organic 
changes are its effects. 

To the pathologist and medical practitioner, the sympathetic phe- 
nomena of inflammation constitute one of the most interesting and 
important objects of attention. Among the multifarious febrile affec- 
tions that are met with in practice, whether acute or chronic, there 
are comparatively but very few in which local inflammation does 
not exist in some organ or structure ; and, although in the majority 
of instances, these inflammations are secondary, or developed after 
the commencement of the fever, their influence in protracting the 
disease, and aggravating its phenomena, is, perhaps, not the less con- 
spicuous. Whenever febrile irritation becomes much protracted or 
chronic in its course, we may infer, with little chance of mistake, 
that there exists some obscure focus of inflammation in an internal 
part. Pure idiopathic or general fever, without the accessory irri- 
tation of local inflammation, can never continne very long. Mere 
morbid excitement, from general causes or movable irritants, is gene- 
raUy soon overcome by the organic, or what has been called the 
sanative actions of the animal economy. 



CHAPTER X. 



OF THE PHLEGMASIA OF THE ALIMENTARY CANAL, AND ITS ACCES- 
SORY ORGANS. 

Sect. I.— Of Glossitis. 

Acute inflammation of the tongue is not a frequent disease; but 
when violent, it is a very severe, and often rapidly fatal affection. 
It usually begins with a burning and throbbing pain in the tongue, 
attended with febrile symptoms, which soon rise to a high synochal 



GLOSSITIS. 205 

grade. The tongue soon becomes hot, dry, red and swollen, the 
swelling generally increasing rapidly, so that in a few hours it 
fills almost the whole cavity of the mouth, and is often thrust out 
between the teeth, appearing like a mass of raw flesh. The respira- 
tion becomes extremely difficult, and a horrible sense of impending 
suffocation is experienced. The patient can neither move the tongue 
nor swallow. In some instances suppuration takes place ; and one 
or more small abscesses are formed in the substance of the tongue, 
which are seen pointing on some part of its surface at the same time 
that the pain and swelling subside. Instances have occurred in 
which mortification of the tongue has taken place, or partial slough- 
ing of its substance ; and the inflammation has been known to termi- 
nate in induration of its structure.* The tongue occasionally swells 
so rapidly and greatly, as to occasion death by suffocation in a very 
short time. I have known a case terminate fatally in less than 
twelve hours from the commencement of the disease. 

More or less inflammation of the tongue generally accompanies 
laryngitis; and it occurs also occasionally in cynanche tonsillaris; 
but in instances of this kind, the inflammation and tumefaction of 
this organ scarcely ever become very considerable. Glossitis may 
arise from the operation of local irritating causes on the tongue ; such 
as acrid substances taken into the mouth ; wounds ; bruises; the sting 
of an insect ; scalding ; calculous concretions in the salivary ducts. 
It may also be produced by atmospheric vicissitudes, or the influence 
of cold and damp atmosphere. Dr. Hosack relates a case which was 
caused by sitting in a current of cold air, immediately after being 
much heated by exercise. Reil states that glossitis has occurred 
epidemically ;t and Stark has known it to come on periodically, in 
consequence of suppressed menstruation, f 

Treatment. — General blood-letting, promptly and decisively prac- 
tised, followed by the application of leeches along the margin of the 
lower jaw, and, if practicable, to the lower surface and extremity of 
the tongue, are indispensable remedial measures in this affection. 
Much advantage may also be derived from scarifying the anterior 
part of the tongue ; and still more from making an incision into its 
substance along the middle. This practice was particularly recom- 
mended by De la Motte§ many years ago; and in a late number of 
the Edinburgh Medical and Surgical Journal, an interesting case is 
related by Mr. Martin, which was successfully treated by incisions. || 

* Richter's Specielle Therapie. Band. i. p. 497. 
t Fieberlehre, torn. ii. p. 411. 

I Handbiich zur Kennt. und Heil. der innern Krankh., p. 140. 
\ Med. de I'Acad. de Chirurg., torn. v. 

II The tongue, in this case, " increased in size until it protruded from the mouth, 
and separated the jaws. The organ was smooth, hard, and covered with a thick 
coating of viscid saliva. The patient was bled to 30 ounces, with some relief — 
and the same quantity of blood was taken in an hour after, which enabled him to 
articulate distinctly. In three hours more, the swelling had increased — respira- 
tion through the mouth was impracticable, and that through the nostrils was difh- 



206 CTNANCHE TONSILLARIS. 

Reil, also, {he. cit.,) speaks strongly in favour oi svperfcinl incisions, 
from an inch and a half to two inches in length, along the middle of 
the tongue. The bleeding must be promoted by emollient gargles. 
Richter says that the swelling generally subsides speedily after the 
incisions; and they readily heal without any disagreeable conse- 
quences. From the impossibility of swallowing, internal remedies 
cannot be employed. Laxative enemata, however, are very useful, 
and should be frequently administered until the bowels are well 
evacuated. Considerable benefit may also arise from a large blister 
laid on the back of the neck or on the throat, after proper general and 
local depletion has been employed. 



Sect. II. — Of Tonsilitis. — Cynanche Tonsillaris. — Quinsy. 

In this variety of angina, the inflammation is seated in the tonsils, 
soft palate, and fauces, and is of a strictly phlegmonous character. 
In cold and variable climates, it is a disease of frequent occurrence, 
and although by no means so dangerous a malady as the anginose 
affections of the respiratory passages, it is much more painful, and in 
violent cases always alarming, and sometimes fatal. 

Symptoms.— T\\e disease usually begins with slight chills, suc- 
ceeded by a high grade of febrile reaction, accompanied with an 
uneasy feeling in the fauces, and more or less pain in this part on 
swallowing. In a few hours, a fixed pain is felt about the region of 
the tonsils, and the act of deglutition becomes more and more pain- 
ful, until at last it is attended with extreme suffering, or altogether 
impossible. On examining the throat, one or both tonsils are found 
very much swollen, and the whole surface of the fauces very red and 
somewhat tumefied. The tongue also is swollen ; white, and covered 
with a thick layer of transparent viscid mucus. The face is red and 
tumid ; the carotids beat strongly ; respiration is difficult ; hearing 
obtuse ; the pulse frequent, hard, and full ; and the voice is indistinct 
or Avhispering. In general, much more difficulty and pain are expe- 
rienced in swallowing liquids than soft or pultaceous solids. The 
pain generally shoots from the fauces into the ears, particularly on 
attempting to speak or to swallow, and the mouth is opened with 
great difficulty and pain. A very thick ropy mucus commonly ad- 
heres to the inflamed parts, and contributes much to the difficulty of 
respiration. The uvula and soft palate are generally very much 
swollen ; but the principal pain and difficulty of breathing arise from 
the tumefied tonsils ; for when both are inflamed, they sometimes 
become so much enlarged as to come in contact with each other, con- 
cult — in short, suffocation was threatened. A deep incision was made in the 
most prominent part of the right side of the tongue, from whence issued a quan- 
tity of blood and pus, with evident relief. Two other incisions were made when 
the first ceased to discharge blood. In a quarter of an hour after the first incision, 
the patient could articulate distinctly — respiration was free. Next day he was 
nearly well.'"' — Med. Chir. Rev., October, 1827. 



.CYNANCHE TONSILLARIS. 207 

fining the tumid uvula behind them, or pressing it forwards into the 
mouth.* The external part of the throat, in the region of the tonsils, 
IS always somewhat tumefied, and tender to the touch. In some in- 
stances, the tonsils are covered whh flakes of coagulable lymph, of a 
whUish colour, resembling superficial sloughs. Occasionally small 
excoriations or ulcerations occur on the inflamed tonsils. These 
, ulcers arise from small yellowish pustules bursting and pouring out 
a lymph-like fluid, which concretes into a whitish pseudo-membran- 
ous layer on the surface of the tonsil. This, after some time, sepa- 
rates, and exposes a bright red and very sensible surface or erosion 
from which a purulent matter is discharged.! ' 

The inflammation in this aflection terminates either in resolution 
or suppuration, gangrene being an extremely rare occurrence. In 
no structure is inflammation more apt to terminate in abscess than 
m the tonsils. Internal suppuration often occurs in a few days, not- 
withstanding the most active local and general antiphlogistic mea- 
sures. The quantity of matter discharged from a suppurated tonsil 
is seldom so abundant as to become very perceptible in the sputa, a 
portion of it, no doubt, being commonly swallowed with the saliva. 
Cases occur, in which the abscess, instead of breaking internally, is 
gradually enlarged, and extending outwards, points externally under 
the angle of the jaw. Dodonoeus relates a case, in which the patient 
appeared near dying, where speedy relief was obtained by an exter- 
nal incision into the abscess, and the consequent discharge of a large 
quantity of pus.J Frequent attacks of the disease are apt to produce 
permanent enlargement and induration of the tonsils. In some 
instances the inflammation passes down into the larynx, an occur- 
rence which always greatly increases the dangerousness of the afl'ec. 
tion. 

Ccwses— Some individuals are peculiarly predisposed to this 
variety of angina. This is especially observed in persons who have 
already once or twice suffered an attack of the disease. The con- 
stitutional influence of mercury, or salivation, appears to create an 
increased aptitude to this aflection ; a strumous habit, also, appears 
to constitute a state of predisposition to the disease. 

The ordinary exciting cause of this complaint is cold and damp 
air, or cold applied in any manner so as to give a sudden check to 
the perspiration. Standing long on cold and wet ground is particu- 
larly apt to give rise to the disease in those who aye predisposed to 
it. It may also arise from local causes, such as irritation from the 
catting of one of the posterior teeth ; (Sachse, loc. cit., p. 475 ;) the 
fumes of arsenic; (Sheffler, von. d. Gesundh. der Bergleute ;) acrid 
substances, swallowed or applied to the fauces. (Fabricius, cent iv 
obs. 15.) V . , 

* We may be sceptical, however, with regard to the assertion of Marcellus 
Donatus, who affirms that he has seen the uvula thus pressed forwards by the 
swollen tonsils, ad anteriores mque denies. — Be Medica Historia Mimbili^ p. 84. 

t Dr. W. Sachse, Encyclopadisches Worderbuch der Medicinischen Wissen- 
schaften. Band, ii, p. 464. 

X Obs. Med., p. 192, as quoted by Van Swieten. 



203 CYNANCHE TOXSILLARIS. 

Trea t me nL— The treatment must be vigorously antiphlogistic; 
and although Culleu asserts that a copious abstraction ot blood is 
seldom necessary, general experience is decidedly in favour of prompt 
and efficient bleeding in this affection. In slight cases we may some- 
times subdue the inflammation without blood-letting, but as we can- 
not be sure, at first, whether the disease will continue a mild course, 
or acquire much severity, it is always best at once to moderate the 
momentum of the circulation by depletion. Local bleeding, by 
scarifying the tonsils, generally produces excellent effects, and may be 
accounted much more efficacious than the application of leeches to 
the throat or under the ears.* Cupping on the back of the neck and 
under the ears, may also be resorted to with benefit. Baglivi asserts 
that he has known the abstraction of blood, by cupping between the 
shoulders, afford great advantage in this affection. Internally, pur- 
gatives and the usual antiphlogistic diaphoretic remedies must be 
actively employed. An active purge should be one of the first reme- 
dial measures adopted ; the bowels must afterwards be kept freely 
moved, either by the daily repetition of purgatives, or frequent laxa- 
tive enemata. A bolus of calomel and jalap, or from fifteen to twen- 
ty grains of the compound extract of colocynth, with ten grains of 
calomel, or a full dose of one of the neutral purgative salts, may be 
used for this purpose. 

Nitre with antimony, in the usual proportion of the nitrous pow- 
ders, constitutes the best refrigerant diaphoretic in this complaint. 
Some advantage may be gained by placing the nitre on the tongue, 
and swallowing it as it is gradually dissolved in the mouth. The 
muriate of ammonia, dissolved in water with the extract of liquorice, 
has also been particularly recommended.t Much benefit may, in 
general, be derived from nauseating doses of tart, emetic. I have 
frequently prescribed this remedy with the happiest effect. A grain 
of tart, antim. may be dissolved in two ounces of water, of which a 
teaspoonful is to be taken every half hour, so as to keep up a con- 
siderable degree of nausea for several hours. 

Emetics were formerly a good deal employed in this variety of 
angina, but their effects are much less beneficial in this than in any 
of the other anginose affections. 

As soon as the momentum of the circulation has been moderated 
by venesection, a blister should be applied to the throat, or on the 
back of the neck. In slight cases of the disease, rubefacients, par- 
ticularly the spirits of turpentine, or a liniment composed of two parts 
of ac. ammonias to one of sweet oil, will in general suffice for this 
purpose. 

Emollient poultices, also, are very useful applications in simple 
cases of the disease. When employed as soon as the disease com- 
mences, together with a warm pediluvium, and a purgative, the further 
progress of the inflammation will sometimes be speedily and effec- 

* Kopp, an eminent German physician, says, that blood drawn from the tonsils 
by scarification, is the best, most certain, and promptest remedy we possess in 
this affection. 

t Loeffler. Beitragen zur Arzn. Wissensch. 1 Th. Leips., 1791, p. 142. 



PAROTITIS. 209 

tually checked. In such instances three or four folds of thick flannel 
round the neck, with the anxiUaries just mentioned, are sufficient fre- 
quently to prevent the development of the malady. In all mstances, 
however, where the inflammation is considerable, vesication is de- 
cidedly the most proper. 

Various gargles and other applications to the seat of inflammation 
have been recommended in this affection. CuUen advises a decoction 
of oak bark, with alum dissolved in it, as a gargle in this disease. I 
have generally preferred using simply warm water, slightly acidulated 
with vinegar, for this purpose. Little or no advantage results from 
the use of gargles in this complaint, beyond that of dissolving and 
removing the viscid mucus which is apt to adhere to the tonsils and 
palate, and this is best effected by warm water, either alone, or with 
a portion of some vegetable acid, and perhaps honey. Pringle states 
that he never derived any benefit from astringent gargles ; and Storch 
asserts, that he has known them to do very evident harm, by check- 
ing the exhalation and seeretion from the mucous surface of the in- 
flamed parts. The inhalation of different vapours is one of the 
oldest remedies in this disease. Hippocrates used the vapour of vine- 
gar and water for this purpose. 

M. Toriac asserts that the application of lunar caustic to the ton- 
sils in the early stage of this complaint, almost always speedily 
arrests the inflammation and swelling. He has related several cases, 
which were completely subdued by this application, in less than two 
hours. In the case of a lady, whose tonsils were inflamed and so 
much enlarged as to threaten suffocation, every disagreeable sensa- 
tion was removed in one hour by the application of the nitrat. 
argent.^ 

When the inflammation has terminated in the formation of a ton- 
sillar abscess, it should be pierced with a lancet, to give exit to the 
matter, an operation which always gives immediate relief from the 
pain and ditficulty of respiration. After the pus is discharged, the 
patient should continue the use of some mild and slightly acidulated 
or astringent gargle. 



Sect. III. — Of Parotitis. 
MuTnps. 

Parotitis is a specific inflammatory affection capable of being pro- 
pagated by a peculiar contagion, and occurring sometimes epidemic- 
ally. 

The disease usually commences with slight febrile symptoms, 
with a feeling of stiffness of the jaws, and a little swelling and pain 
either in one or both parotid glands. The swelling gradually in- 

* The Amer. Jour, of the Med. Sciences, vol. v, p. 212: quoted from La Cli- 
nique, &c. ' 

VOL. I. 14 



210 PAROTITIS. 

creases until about the fourth day from the beginning of tlie disease, 
at which time the affected gland is greatly swollen and very firm 
and tender to the touch. The skin on the tumour is generally of a 
natural colour, or but slightly inflamed ; although, in some iiistances, 
a pale redness is diffused over the swelling. Mastication and deglu- 
tition are always attended with considerable pain. The fever is 
generally mild, "and is often attended with considerable nervous 
irritability and restlessness. From about the fourth day the swelling 
gradually subsides until the detumescence is complete, which is gene- 
rally about the seventh day. Soon after the inflammation of the 
parotids begins to decline, the breasts in females, and the testicles in 
males, are apt to become much swollen and hard. The subsidence 
of the disease is usually attended with more or less general diaphore- 
sis, and a red sediment in the urine. 

In general, parotitis is neither a severe nor a dangerous aflfection — 
more especially when the patient keeps the affected parts moderately 
warm, and avoids exposing himself to the injurious influence of vari 
able or low temperature. In some instances, however, a sudden 
metastasis of the inflammation takes place to the brain, or to the tes- 
ticles, or the mammae — and this is generally occasioned by the patient 
taking cold. When it passes to the brain, insensibility, coma, or furi- 
ous delirium usually supervenes, and death sometimes occurs in a 
few hours. I have known a case of this kind terminate fatally in 
less than an hour under a paroxysm of violent convulsions. When 
the disease thus suddenly falls on the testicles, and the case is not 
judiciously treated, suppuration of these parts may take place— an 
occurrence always exceedingly painful, and sometimes ultimately 
fatal.* The inflammation of parotitis, however, has no tendency to 
terminate in suppuration ; yet, when circumstances favourable to this 
termination supervene, it does sometimes take place in the parotids, 
as well as in the external parts, to which it may be transferred. 

Children and young persons are most liable to this affection— its 
occurrence in middle and advanced age being very uncommon. It 
very rarely occurs more than once in the same individual, and resem- 
bles in this respect the other acute contagious maladies. 

Treatment. — In mild cases, little more is necessary than keeping 
the bowels open, and using gentle diaphoretics. The parts should be 
kept warm — great care must be taken to avoid taking cold. When 
the inflammatory symptoms are violent, an active antiphlogistic treat- 
ment is necessary. When the swelling disappears in the neck, and 
shows itself in the testicles, a blister should be laid on the parotids, 
and every effort made to excite a general diaphoresis. To discuss the 
hard swelling which sometimes remains after the inflammatory symp- 
toms have disappeared, frictions on the tumour, with mercurial oint- 
ment, spirits of camphor, or rubefacient liniments, should be used. 

* [It is a vulgar opinion, and sometimes a well founded one, that atrophy of the 
testes is liable to follow a translation of mumps to these organs. One celebrated 
character was emasculated in this way, and I have known of another case which 
happened within my own circle of acquaintance. — Mc] 



ACUTE GASTRITIS. 211 

Of the Inflammation of the Alimentary Canal. 

Inflammation of the mucous membrane of the alimentary canal 
has, of late years, attracted more attention than, perhaps, any other 
phlegmasial affection. The French path6logists, in particular, have 
investigated this subject extensively, and most minutely. Whether 
their peculiar views concerning the connection of this local affection 
with general fevers, be correct or not, it cannot be doubted, that it is 
pre-eminently entitled to the attention of the pathologist and practi- 
tioner. I have already frequently adverted to the great tendency of 
some forms of fever to give rise to miicous inflammation of the ali- 
mentary canal ; and the practitioner who does not attend to this cir- 
cumstance, will incur a liability to defeat in his remedial efforts, whicli 
cannot be justified in the present state of pathological science. It is, 
indeed, of the utmost importance, that the medical practitioner should 
make himself familiar, not only with the general fact just referred to, 
but especially with the various phenomena, both primary and second- 
ary, of gastro-enteric inflammation. It is not, however, our purpose, 
in this place, to treat of this affection in reference to its connection 
with idiopathic fever. The disease is here considered as a primary 
aff'ection — the immediate and only cause of the general symptoms 
which accompany its course, and which necessarily cease with the 
cessation of the local inflammatiou. 



Sect. IV. — Of Acute Gastritis. 

Symptoms. — Acute inflammation of the mucous membrane of the 
stomach commences sometimes with violent vomiting and purging, 
attended with a burning or lancinating pain in the stomach. In some 
instances, a prickling pain and soreness in the pharynx, without much 
gastric irritability, are the first symptoms of the disease ; and occa- 
sionally it begins with great tenderness in the epigastrium, nausea, 
retching and vomiting. In nearly all instances, frequent and painful 
vomiting, especially immediately after swallowing warm liquids, is a 
prominent symptom. The desire for cool drinks is generally ex- 
tremely urgent ; but the aversion to warm liquids is almost equally 
strong. After each spell of vomiting, the patient usually experiences 
a temporary abatement of the gastric distress; and a similar transient 
alleviation often follows the reception of cool and bland liquids into 
the stomach. Warm drinks, on the contrary, rarely fail to aggravate 
the pain and vomiting, as soon as they arrive in the stomach. In 
some cases, there is a considerable difficulty of swallowing, on account 
of the contracted and irritable state of the upper orifice of the sto- 
mach. Oppressed and anxious respiration occurs in many instances, 
from "the inflamed state of the stomach rendering the descent of the 
diaphragm painful." (Broussais.) The brain occasionally sympa- 
thizes strongly with the inflamed stomach. Broussais has seen pa- 
tients in this disease "as completely delirious as in fevers of the most 
malignant character, or phrenitis." The delirium, in such instances, 



212 ACUTE GASTRITIS. 

is almost always greatly subdued, for a short time, by a draught of 
cold water. Acute gastritis is generally attended with great depres- 
sion of spirits, and prostration of strength ; and the pulse, though at 
first moderately full, soon becomes very contracted, quick, and tense, 
and at last so small as scarcely to be felt. A short and painful cough 
attends in some cases, and the voice usually becomes much altered, 
and sometimes entirely extinct from paralysis of the laryngeal mus- 
cles. The aspect of the countenance is expressive of great anxiety 
and suffering, or of despondency and despair. 

When the inflammation is confined to the stomach, the bowels are 
constipated ; but where the colon becomes involved in the disease, 
diarrhoea, or tenesnms, with dysenteric discharges, attends. The skin 
is dry, and generally hot ; and the tongue often red and clean, or co- 
vered with a thick layer of white fur along the middle, with a red and 
granulated border. Towards the conclusion of fatal cases, hiccough, 
laintings, cold extremities, slight delirium, coma, and cold, clammy 
sweats occur. 

Such are the more prominent symptoms which usually attend this 
affection. Acute gastritis does not, however, always manifest itself 
by these unequivocal phenomena. In some instances, the inflam- 
mation is developed and proceeds to fatal disorganization^ in so 
obscure and insidious a manner, as to present scarcely any of the 
ordinary manifestations of its existence. Dr. Abercrombie* justly 
observes, that the symptoms which attend acute inflammation of the 
stomach, are liable to great uncertainty. The records of medicine 
furnish us with many instances, in which the most striking traces of 
previous inflammation were detected in the stomach on post-mortem 
examination, but which exhibited none of the symptoms by which 
the presence of this affection is usually ascertained. 

I have recently met with a case, in which the patient complained 
of intense pain in the head, with occasional slight delirium, transient 
darting pains through the chest, nausea, with an indescribable feeling 
of distress in the epigastrium ; a frequent, firm, and contracted pulse ; 
but without any actual pain in the stomach, or other symptoms that 
could be regarded as characteristic of gastritis. The patient, in the 
course of five days, sunk under his malady. On post-mortem exami- 
nation, nearly the whole internal surface of the stomach was found 
minutely injected, and large patches of the mucous membrane were 
softened, abraded, and, in some parts, very conspicuously thickened, 
and of a yellowish ash-gray colour. No other local affections, whether 
in the abdomen, thorax, or head, were noticed. 

Diagnosis.— Acute gastritis, in its ordinary developed character, 
may be distinguished from cramp and flatulent pains by the follow- 
ing distinctive circumstances. In gastritis, the pulse is small, tense, 
and quick; in spasm, or flatulent pains, it is generally full, or nearly 
natural. In gastritis, violent vomiting generally occurs, particularly 
after taking warm fluids into the stomach. In spasm, vomiting 

* Pathological and Practical Researches on the Diseases of the Stomach. 
Edinburgh, 1828. 



1. 
ACUTE GASTRITIS. 213 



rarely takes place, and warm drinks do not readily excite or aggra- 
vate it. The pains seldom intermit in gastritis, except immediately 
after taking some cool and bland fluid into the stomach, or for a few 
moments after vomiting. In spasm the pain often intermits wholly 
for several minutes, independently of the effects of cool drink or 
vomiting. In gastritis, the patient almost always lies on his back, 
and moves himself as little as possible. In cramp, he sits up or 
walks about, with the body bent forwards, or throws himself about 
on the bed. The pain in gastritis is burning and lancinating; in 
spasm, it is heavy, twisting, aching and extremely severe. In gas- 
tritis, the skin is hot and dry ; in spasm, it is usually moist, and rather 
cool. In gastritis, finally, pressure on the epigastrium is attended 
with a sense of great soreness, and an increase of the pain; in cramp, 
pressure generally affords some relief from the violence of the pain. 

Causes. — Substances of an irritating or corroding character, re- 
ceived into the stomach; cold water rapidly swallowed when the 
body is heated, and in a state of free perspiration from fatiguing 
exercise; over-distension of the stomach by stimulating or indigesti- 
ble food; stimulating drinks; the external application of cold; the 
suppression of habitual sanguineous discharges ; metastasis of rheu- 
matism and gout; external mechanical injuries of the epigastrium ; 
— all these causes may give rise to acute gastritis. 

Besides the foregoing manifest causes of acute gastritis, there are 
others of an occult character which appear to possess a specific tend- 
ency to excite inflammation of the stomach. Of these, the miasm 
which produces yellow fever is the most remarkable. Acute gastritis 
occurs, also, very frequently, in other forms of malignant fevers, par- 
ticularly in the putrid typhus of warm climates. 

Prognosis. — A gradual subsidence of the pain, and disposition to 
vomit, accompanied with a lateritious sediment in the urine, spon- 
taneous feculent alvine discharges, a gentle moisture of the skin, and 
a more developed compressible pulse, indicate a favourable termina- 
tion. When, on the contrary, the pain and vomiting continue with 
tmabated violence for several days, with difficulty of respiration and 
hiccough, the pulse becoming smaller, more frequent, and corded, the 
worst consequences are to be dreaded. If, after the symptoms have 
continued in this progressive course of aggravation, the pain sud- 
denly subsides, and the extremities become cold and clammy, with 
dimness of sight and slight delirium, a fatal termination is inevitable. 

Post-mortem appearances. — In some instances of great violence, 
the disease proves fatal before gangrene or disorganization has taken 
place in the inflamed mucous membrane. Broussais thinks, that 
ill such cases death takes place " from the sole effects of pain, and 
before the inflamed texture is broken down or sensibly altered in its 
composition. Those who had died in the early stage of the com- 
plaint, frequently showed nothing more on dissection than discolora- 
tion, without erosion or ulceration of the mucous membrane." In 
the majority of fatal cases, however, the mucous membrane presents 
strong marks of disease. It is frequently thickened, dense, and 
minutely injected, "exhibiting the character of ecchymosis;" erosion 



214 ACUTE GASTRITIS. 

and ulceration also are a common occurrence, and in many cases 
different parts of this membrane are in a softened or broken down 
state, and of a pale yellow or dark brown colour. 

Treatment.— Bleeding here, as in the other phlegmasial affec- 
tions, stands at the head of our remedial means. The smallness and 
frequency of the pulse must not deter the practitioner from the use 
of the lancet. On the contrary, when the existence of acute gastric 
inflammation is unequivocal, this contracted state of the pulse ought 
to be regarded as the most urgent indication for prompt and copious 
depletion. In general, all the symptoms remit after an efficient 
abstraction of blood. The remission, thus procured, is, however, 
seldom of long duration — an exacerbation usually coming on in an 
hour or two, demanding a repetition of the use of the lancet.* Next 
in importance to prompt and copious bleeding, is the application of 
leeches, followed by a large blister over the epigastrium. When 
leeches cannot be had, a vesicatory, sufficiently large to cover the 
whole epigastric region, should be at once applied ; for as four or five 
hours must elapse before the blister can inflame the skin, sufficient 
time is allowed to moderate the momentum of the circulation, and 
the general phlogistic state of the system, by prompt and copious 
depletion, to obviate any injurious consequences from the general 
stimulating effects of the blister. The blister should be dressed with 
mercurial ointment. 

The ordinary internal antiphlogistic remedies, such as nitre, anti- 
monials, and cathartics, are entirely inadmissible in this affection. 
Considerable advantage may be obtained from the free use of mild 
mucilaginous drinks, such as flaxseed tea, infusion of althea, or of 
marsh-mallows, or of the common malva rotundifolia of this coun- 
try, thin barley-water, or a solution of gum arable in water. I have 
used an infusion of the slippery-elm bark, in a few instances, with 
much apparent advantage. The vegetable acids, diluted with some 
bland mucilaginous fluid, sometimes relieve the gastric distress con- 
siderably, more especially the lemon-juice. Broussais says, that 
"orange-juice diluted in water forms an excellent drink in this dis- 
ease." The mineral acids are alway injurious. 

Costiveness must be obviated by laxative enemata ; and this should 
he particularly attended to, throughout the whole course of the disease. 
For this purpose, we may use the following : 

K. — 01. ricini ^ij. 

Sapoii. veuet. 3J. 

Infus. sera, lini^viij. — M. fiat enema. 

Opium is a valuable remedy in this affection. After the general 

* Brou.?sais does not seem to place a great deal of reliance on the employment 
of venesection in this affection. "La saignee," he observes, "n'eteint point un 
phlogose de I'estomac, comme elle emporte un peripneumonie, et qu'elle est 
inutile .sans le concours des emolliens. J'ai eu assez lieu de me convaincre que 
les evacua'ions sanguines sout'd'un bien faible secours dam Ics inflammations 
des organes plats et membraneux, lorsqne ces tissues ne sont point appliques surunparan- 
chi/mc." — Phlegmas. Chron., vol. ii, p. 20. 



CHRONIC GASTRITIS. 215 

phlogistic conditioii of the system has been considerably moderated 
by venesection, full doses of opium rarely fail to allay the pain and 
vomiting, and to excite a general and salutary action of the cutaneous 
exhaleiits. "Opium," says Dr. Armstrong, " when given in health, 
constipates the bowels; but this is so far from being the case in gas- 
tritis and enteritis, that it tends to assist the action of purgatives, and, 
when exhibited in conjunction with proper depletion, it may be fairly 
accounted one of our best remedies. The two most remarkable 
effects of full doses of opium in gastritis, are relief of the pain and 
reduction of the pulse ; so that the patient often falls asleep shortly 
after their exhibition, and the pulse which had been previously small 
and quick, will become full and small." Some writers recommend 
the use of this narcotic in combination with calomel in the present 
disease. " Pills, with a grain of calomel and a grain of opium, ad- 
ministered three or four times daily, will be found sometimes to allay 
pain and arrest inflammatory action in acute gastritis."'^ I have 
myself sometimes employed this combination with great advantage. 
When opium is employed in this affection, it ought to be given in 
large doses, and repeated so as to keep up a continued impression on 
the system. In two of the most decided cases I ever saw, two grains 
of opium were administered every three hours, until eight grains 
were taken, and with the happiest effects. Efficient blood-letting, 
both general and local, should always be premised to the employ- 
ment of this, narcotic. t 

During convalescence from this disease, the utmost care is neces- 
sary to avoid taking solid and stimulating articles of food and drink. 
Nothing but the blandest liquid nourishment should be allowed — 
such as oat-meal gruel, boiled milk, barley-water, beef or chicken- 
tea,, or preparations of arrow-root, sago, rice, or tapioca. 



Sect. V. — Of Chronic Gastrilis. 

Chronic inflammation of the mucous membrane of the stomach 
is one of the most common phlegmasial affections. The worst forms 
of dyspepsia, and all that host of inveterate gastric and bilious dis- 
orders of which so much is heard, and the true nature of which is so 

*A Compendium of Theoretical and Practical Medicine. By David Uwins, 
M. D., 1828. 

t [I have lately been called into consultation in two distressing and dangerous 
cases of acute gastritis — in both of which speedy and permanent relief was 
aflforded by the administration of full doses of the nitrate of silver. Half a grain 
was given in a pill with one grain of ext. Hyoscyami at short intervals, until every 
symptom weis allayed. In the case of a lady, whom I attended with my brother, 
Dr. Samuel McClellan and Dr. Shallcross of this city, immediate relief was 
afforded to the most painful and incessant vomiting, and a long-continued sense 
of a lump of red-hot iron on the stomach. This patient had begun to sink into 
hopeless prostration and coldness, and actually threw up considerable quantities 
of the real black vomit in the course of her attack. — Mc] 



216 CHRONIC GASTRITIS. 

Often misunderstood, are in nine cases out of ten the consequences of 
a chronic inflammatory condition of the hning membrane ot the 
stomach. The slow and insidious progress of this grade ot gastric 
inflammation during its early period, is indeed well calculated to 
elude observation, and to lead to a misapprehension ot its true cha- 
racter. In many cases the first symptoms are those which usually 
characterize indigestion— such as acidity, flatulence, a sense ot heavi- 
ness and oppression after eating, eructations, and transient slight 
pains in the region of the stomach. When the stomach is empty the 
patient feels easy, but generally languid and dissatisfied, and often 
tormented with a craving and capricious appetite for food. As the 
disease advances, the epigastrium becomes somewhat tense, and sore 
to the touch, and nausea or vomiting is apt to occur an hour or two 
after taking food. The gastric distress gradually becomes more and 
more troublesome, particularly after eating; the patient complaining 
of a constant distressing sensation, amounting sometimes to actual 
pain in the epigastric and right hypochondriac region. The pain in 
the stomach is generally confined to a circumscribed spot, and is of a 
lancinating and stinging character. A sensation of pressure against 
the diaphragm, as if by a large ball, is occasionally experienced by 
some patients, whilst others complain of a feeling as " if a bar were 
fixed across the stomach, preventing the passage of food or drink 
into the stomach." (Broussais.) In some instances, a fluid resem- 
bling the white of eggs is copiously thrown up from the stomach, and 
many complain of a constant and most painful feeling of pyrosis. 
(Abercrombie.) Andral mentions a case in which four pints of a 
glairy fluid were thrown up every twenty-four hours, without any 
portion either of the food or drinks she took coming ofl" with it. In 
the advanced periods of the disease, the appetite almost always fails 
entirely, and in very aggravated cases " there is a general abhorrence 
of food." Costiveness almost universally attends the disease in the 
first periods of its progress ; but in many instances diarrhoea ultimate- 
ly ensues, accompanied with tormina, and sometimes with mucous 
and bloody stools, and more or less tenesmus. The patient is gene- 
rally dejected, morose, impatient, of an irritable temper, and "but 
little disposed to enter into a detail of his sufferings." In general, 
the cheeks and prolabia are of a deep red colour, the tongue is often 
clean, smooth, and of a vermilion tint over the whole anterior sur- 
face, or red and granulated, " somewhat like the points upon a straw- 
berry, with deep fissures, or covered with a streak of brown fur along 
the middle, with red and clean edges." In the advanced stage of the 
disease, emaciation always goes on rapidly, the cellular and adipose 
structures becoming almost entirely absorbed ; in inveterate cases the 
skin is brown, inclining to yellow, and is drawn tightly over the mus- 
cles, sinking into their interstices, so as not to be pinched up without 
much difliculty, even where it usually is most relaxed. (Broussais.) 
In some instances a slight cough attends, but the function of respira- 
tion is rarely much disturbed. The pulse is generally quick, and 
more or less tense, though not often accelerated in the beginning, 
except soon after eating ; but in the latter periods it becomes con- 



CHRONIC GASTRITIS. 217 

tracted, hard, and frequent. There generally exist much muscular 
prostration, and great indisposition both to bodily and mental exer- 
tion. The disease often continues for many months, gradually ac- 
quiring strength as it advances, until the system becomes exhausted 
under a wasting and slow irritative fever, and life is extinguished. 

Chronic gastritis is not always marked by symptoms so conspicu- 
ous as to render its existence very obvious. The inflammation some- 
times proceeds in so obscure a manner as to terminate in fatal disor- 
ganization, with scarcely any accompanying manifestations of a serious 
import. I attended a child which appeared to labour only under tri- 
lling gastric derangement, with occasional slight febrile exacerbations. 
Death occurred unexpectedly in the third week of its indisposition ; 
on dissection, a large circular spot of the mucous and muscular coats 
of the stomach was entirely softened and broken down, and of a 
yellowish-gray colour. Andral has related several cases illustrative 
of the insidious progress of this malady. In one case no suffering or 
uneasiness in the stomach was complained of by the patient until 
eighteen hours before death. 

In some cases, after a few weeks, or perhaps months, of slight un- 
easiness in the stomach, sudden vomiting with prostration and vio- 
lent pain in the epigastrium occurs, and speedily terminates in death, 
iinder symptoms of peritonitis, in consequence of the unsuspected 
inflammation in the stomach perforating its coats, and giving exit to 
its contents into the cavity of the abdomen. When the inflamma- 
tion terminates in perforation of the stomach, death generally occurs 
from the sudden supervention of peritonitis. In such cases, after an 
indefinite period of gastric disturbance, sudden and extremely severe 
pain occurs in the epigastrium, attended by vomiting or retching, " as 
if some acrid poison had been taken into the stomach." Chronic gas- 
tritis is frequently connected with more or less phlogosis of the supe- 
rior portion of the intestinal tube. 

Causes. — Chronic gastritis may be the consequence of the acute 
form of the disease ; but it is much more commonly the result of irri- 
tating substances acting immediately on the internal surface of the 
stomach ; — such as indigestible, heating, or irritating articles of food 
and condiments ; acrid medicinal substances ; insufficient and innutri- 
tions articles of food, in conjunction with habitual exposure to damp 
and cold situations, or mental despondency ; the intemperate use of 
alcoholic liquors ; repelled cutaneous eruptions ; suppressed habitual 
discharges ; neglected or ill-managed dyspepsia. 

The depressing mental emotions, if they do not actually excite the 
disease, are among the most powerful predisposing causes of this 
distressing malady. The united influence of despondency and crude 
innutritions food appears to be peculiarly apt to give rise to this grade 
of gastric inflammation. The development of the disease is often 
very gradual, commencing in mere debility of the digestive powers, 
wliich, without great attention to dietetic rules, leads to irritation, and 
finally to chronic inflammation of the internal surface of the stomach. 
Over-distension of the stomach by food or drink, especially when 



218 CHRONIC GASTRITIS. 

habitual, and when the ingesta are of a stimulating character, is a 
common source of this affection. u ^■\ 

Diagnosis.— hi its early periods, chronic gastritis may be readily 
mistaken for dyspepsia ; for its symptoms often differ but litde from 
those which occur in the latter disease. When, however, the patient 
feels considerable pain i?i a particular spot, i'oWowed by vomiting 
soon after eating, and a severe feeling of pyrosis attends, with redness 
and tenderness of the tongue and throat, and the patient becomes 
much weakened and emaciated, we may reasonably suspect the 
existence of chronic gastritis. 

Considerable difficulty often exists, in distinguishing chronic gas- 
tritis ixom gasiralgia — a neuralgic affection wholly unconnected with 
inflammation. There can exist no doubt that this malady has been 
frequently mistaken for chronic gastritis ; and as the modes of treat- 
ment appropriate to each are diametrically opposite, it is manifestly 
of the utmost importance to learn to distinguish them from each other. 

Mr. Barras has published some interestmg observations on gastral- 
gia, and on its liability to be mistaken for chronic gastritis. He 
gives the following, among others, as diagnostic symptoms between 
these two affections.* 

1. "In chronic gastro-enteriiis,i\\Q pain is generally oi/t6?e ; often 
felt only on pressure ; is never absent. Gastralgic pain, on the other 
hand, is often extremely violent ; is often, when most violent, relieved 
rather than increased by pressure. It often radiates from the epi- 
gastrium towards the thoracic parietes, the back, and the shoulders ; 
is of an intermittent character, sometimes entirely disappearing, to 
return with more or less violence. 

2. " In chronic gastritis, the tongue, which is generally red on the 
sides and at the tip, is covered in the middle with a kind of dry 
mucous crust, resembling a false membrane ; the breath is fetid, with 
a bitter taste in the mouth ; there is thirst. \n gastralgia the tongue 
is white ; saliva abundant ; no thirst, but sometimes a repugnance 
even to hquids. 

3. " In gastritis, the appetite is always bad, and sometimes amounts 
to a universal disgust for every kind of food. In gastralgia, the 
appetite is variable, null, slight, natural, often greater than in health. 

4. " In chronic gastritis, the ingestion of a small quantity of food 
renews the patient's sufferings ; excites as a febrile movement in the 
system, and the digestion is always imperfect. There is often rejec- 
tion of the food by vomiting a little time after eating ; or if there be 
no vomiting, the patient is oppressed, during the digestive process, 
with a sense of weight, distension, nausea, acid, or acrid eructations, 
and irritation of the bowels, or diarrhoea, in the advanced stages. In 
some cases of gastralgia, the pain is relieved, at least for a time, by 
eating food in considerable quantity, and the digestion is complete, 
or even too quick. In most cases of gastralgia, however, the presence 
of food in the stomach renews the pain ; but not till some time after 
eating; generally, one, two, or even three hours; at which time the pa- 

* Revue Medicale; November and December, 1825 



CHRONIC GASTRITIS. 219 

ticnt experiences weight and malaise at the epigastrium, as if a foreign 
body were lodged in the stomach. There are nausea, borborygmi, 
flatulent colic, eructations of air, but without fetor or causticity. 
Sometimes, indeed, patients will taste the aliments that they have 
swallowed in the air which they eructate, but the digestion is com- 
pleted, and diarrhoea is very rare. Constipation is generally obstinate, 
and the urine, especially when the gastralgia is in a high degree, is 
usually pale, voided frequently, and in small quantities at a time. 

5. '• (Chronic gastritis never fails to impair the process of nutrition, 
inducing hectic fever, characterized by hardness and frequency of the 
pulse, heat of the skin, and evening exacerbations, with loss of flesh 
and strength, sallowness of the countenance, with a peculiar dark 
tinge, and finally death. 

G. " In some violent and prolonged cases of gastralgia, the pa- 
tient experiences difficulty of breathing, palpitations of the heart, 
wandering pains, and peculiar sensations of coldness, especially in 
the arms, loins, and lower extremities. The sleep is sometimes good, 
sometimes agitated, sometimes null ; yet, in the mornings, the patient 
gets up refreshed, and feels quite well, till breakfast renews the gas- 
tric sensibility. Nothing of this kind obtains in latent gastritis. 

7. " Those who are aflected with chronic inflammation of the di- 
gestive tube are melancholy, morose and impatient ; but this is nothing 
to the state of moral depression and anxiety which obtains in ^r/.s/ra/- 
gia. In this last, there is ineffable despondency ; disgust of life, or 
fear of death in the extreme ; the slightest sensation in the stomach 
awakens the patient's terrors; he is tremblingly alive to every look 
of his physician — to every word which is spoken by his friends re- 
specting his complaint ; he is afraid of taking any thing into his sto- 
mach, as he knows, by doing so, he will aggravate the complaint ; 
he is convinced that his disease is mortal — becomes entirely absorbed 
by his own sensations, and indiflerent to every thing else. But any 
diminution or sensation of the gastralgia immediately changes the 
scene from despair to sanguine hope — to be again reversed on the 
slightest accession of pain." 

Dr. Armstrong observes, that the effects of a difl'usible stimulus — 
such as wine, brandy, &c., will generally remove all doubts as to the 
presence of the one or the other of these affections. In gastritis, the 
pain and uneasiness in the stomach are always increased by potations 
of this kind ; whereas, in gastralgia, relief is generally the result.* 
Whenever fever, pain, and anorexia occur after the operation of an 
emetic we can no longer doubt the existence of chronic gastritis. 
(Broussais.) 

Post-mortem appearances. The organic changes effected in the 
stomach by chronic inflammation of its villous coat, are very various. 
In almost all fatal cases, more or less ulceration is found in the stomach ; 
and these ulcers exist in various forms and stages of progress. Some- 
times a single ulcer, not above a quarter of an inch, occurs, the other 

* The INIorbid Anatomy of the Bowels, Liver, and Stomach. Fasciculus, i and 
ii, London, 1828. 



220 CHRONIC GASTRITIS. 

portions of the mucous membrane being in a healthy condition. Oc- 
casionally, we find various ulcers— some partly cicatrized, others just 
beginning, and others again, deep with loss of substance, and rounded 
and elevated edges. When the ulcerated surface is large, there are 
« generally thickening and induration of the coats and fungoid eleya- 
tions."' (Abercrombie.) Sometimes the only organic lesion consists 
in a thickening of the mucous membrane, in different parts of its 
extent, of a pale ash, or brown, or dark colour resembling melanosis. 
In other instances, portions of the mucous membrane are softened or 
broken down, or entirely destroyed.* Cases occur, however, in which 
no organic changes whatever are detected in the mucous membrane 
on dissection. In instances of this kind, the subjacent cellular tissue, 
says Andral, is found in a diseased state— and this is particularly ob- 
servable in that condensed and whitish membrane between the villous 
and muscular tunics of the organ. (Med. Chir. Rev.) Andral observes, 
that thickening and induration of the mucous membrane, are one of 
the most certain marks by which chronic may be distinguislied from 
acute gastritis. Softening of this membrane, is, however, the most 
frequent of all the organic changes effected in this disease.t In some 
unequivocal cases of chronic gastritis, M. Andral found nothing but 
stripes of thickened and condensed mucous membrane, and of a 7;^/^^ 
colour than natural. In one very strongly-marked case, nothing 
bat a patch of a milky white colour, with slight thickening and 
induration of the mucous membrane, was discovered on the stomach 
on dissection. 

Treatment. — In the treatment of this variety of gastric inflamma- 
tion, almost every thing depends on proper dietetic regulations. It 
is obvious, that every thing which tends to irritate the stomach, must 
be particularly calculated to favour the progress of the disease, and 
to aggravate the sufferings of the patient. It is, therefore, of the 
utmost importance in the remedial management of this affection, to 
allow nothing in the way of nutriment, but the blandest and least 
irritating articles of diet that can be contrived. Mucilaginous liquids, 
such as decoctions of barley, rice, thin gruels, and fluid preparations 
of arrow-root, tapioca, or sago, or boiled milk, and animal jellies, 
constitute the appropriate nourishment for patients affected with this 
disease. All solid articles of diet should be especially avoided. 

Leeching or cupping over the region of the stomach is another 
of our most efficient means for subduing this distressing affection. 
Much benefit will also sometimes accrue from the application of a 
blister to the epigastrium ; or, what has appeared to me still more 
useful, frictions with tartar emetic ointment, until pustulation is pro- 
duced. Leeching and blistering should be used, from time to time, 
in alternation. 

* Pathological and Practical Researches on Diseases of the Stomach, &c. By 
John Abercrombie. 

t Memoir sur les Caracteres Anatomiques de la Gastrite Chronique. Par 
M. Andral, Repertoire Generale, Nos. 1 and 2, 1824.— See Med. Chir. Rev., Jan. 
. 1827. 



ACUTE ENTERITIS. 221 

Among the internal remedies useful in chronic gastritis, the sidph. 
Jerri is, probably, the most valuable. Dr. Abercrombie speaks very 
favourably of its effects in this complaint — and Dr. Armstrong re- 
commends it as a remedy of considerable value. Within the last 
two years, I have employed it in several cases with very decided 
advantage. Dr. Abercrombie administers it in doses of two grains, 
with a few grains of aromatic powder, twice or thrice daily. I have 
never given more than one grain at a dose, and indeed very seldom 
more than half a grain. It has appeared to me most beneficial when 
given in union with the extract of hyoscyamus. Haifa grain of the 
sulphate with a grain of this narcotic, and an eighth of a grain of 
sulph. morphia, maybe given four times in the course of twenty-four 
hours. I have, also, employed the nilrate of silver, in small doses, 
with very evident benefit in cases of this kind. It should be adminis- 
tered wuh a considerable portion of some bland mucilaginous fluid. 
In a case for which I lately prescribed, very excellent effects were 
obtained from the use of five grains of powdered borax, in union 
with four grains of Dover's powder, three times daily. Balsam 
copaiva has been particularly recommended in chronic inflammation 
of the alimentary canal. In small doses, I liave used the following 
mixture, in a few well-mark€d cases of this complaint, with consider- 
able benefit. 

K.— Bals. Copaiv. ^iss. 

P. g. arab. gij. 

Syrup, limonis ^ss. 

Aq. fontariEE ^viij, 

Tinct. opii acetat. gtt. 30. — M. S. A small tablespoonful twice daily. 

To palliate the distressing sensations in the stomach, as well as 
the general irritability both of mind and body, two or three grains 
of Dover's powder may be given at night on going to bed. For this 
purpose I have employed the lupuline with much benefit. From 
four to srx grains of this preparation may be given once daily. The 
syrup of poppies may also be advantageously used, as an occasional 
anodyne in this affection.* Care must be taken to procure regular 
alvine evacuations. This, however, cannot be prudently effected 
by laxatives taken into the stomach; for however mild they may 
be, they will almost inevitably do mischief by irritating the morbid 
mucous membrane of the stomach. One or two purgative enemata, 
administered at stated hours daily, rarely fail to procure all that 
may be desired in this respect. 



Sect. VI. — Of tBaite Enteritis. 

Acute inflammation of the intestinal canal occurs under two forms, 
sufficiently distinct in their pathological characters and phenomena, 
to require separate consideration. In one of these varieties, the in- 
flammation is seated chiefly, perhaps in some instances exclusively, 

* [The ait. arg. is infiaitely the best remedy in this state. — Mc] 



222 ACUTE ENTERITIS. 

in the peritoneal and muscular coats of the intestines; and in the 
other, the inflammation is confined wholly, or in a great measure, 
to the internal or mucous membrane. In the first, constipation is 
almost universally present ; in the second, mucous discharges, with 
more or less blood and tenesmus, are rarely absent. 



1. Jiciite Peritoneal Enteritis. 

Sr/mpto7ns. — This disease often commences with a feeling of un- 
easiness in some part of the abdomen, terminating, after a longer or 
shorter period, in a fixed aching or burning pain, referred usually to 
the umbilical region. In some instances, the pain is confined to a 
circumscribed part ; but it more frequently becomes diffused through- 
out the whole abdomen. Obstinate constipation almost invaria- 
bly exists — except the inflammation extends to the mucous mem- 
brane of the colon or rectum, which, however, occurs but very 
rarely, when dysenteric discharges, with tenesmus and tormina at- 
tend. Nausea and vomiting are frequent and very distressing at- 
tendants on the disease ; the latter often becoming so constant and 
violent as to communicate the inverted action of the stomach to the 
bowels, causing stercoraceous matter to be thrown up. The tongue 
is dry, and generally covered with a white fur, sometimes of a pale 
red round the edges, with a streak of brown fur along the middle ; 
the thirst is urgent ; the urine scanty, high coloured, and frequently 
discharged with considerable difficulty ; the skin hot and dry on the 
trunk of the body, but often moist on the forehead and in the palms 
of the hands ; the pulse small, frequent and tense ; and the respira- 
tion almost always more or less disturbed— being usually short, 
anxious, and performed by the action of the intercostal muscles ex- 
clusively. To avoid pain from the pressure of the abdominal mus- 
cles on the inflamed bowels, the patient lies on his back, with the 
knees drawn up, and the shoulders raised by pillows, by which the 
tension of these muscles is diminished. Sometimes acute peritoneal 
enteritis is ushered in "by a sort of rigor," exhibiting, in its subse- 
quent course, two distinct stages — one of excitement, and the other 
of collapse, resembling, in this respect, acute peritonitis. In the 
stage of collapse, the extremities become cold, and at last damp, 
" while the fingers and hands are generally mottled by a dun sort of 
redness here and there." The pulse becomes weaker and weaker, 
tmtil it feels under the finger <' like a soft undulating line." Great 
prostration of the muscles exists; the "face becomes death-like; the 
abdomen tumid and tense ;" and, lastly, a sort of passive gulping 
generally takes place, the contents of the stomach being apparently 
forced up the oesophagus by the pressure of the intestines, which are 
then, for the most part, enormously distended with flatus.* 

Peritoneal enteritis is generally rapid in its course, and is peculiarly 
prone to terminate in gangrene. When this termination is about 

* Armstrong's Morbid Anatomy of the Bowels, Liver and Stomach; &c. 



ACUTE ENTERITIS. 223 

taking place, the pain suddenly subsides ; the pulse sinks rapidly, 
the countenance becomes pale and cadaverous; the extremities cold • 
the surface covered with a cold clammy sweat, and hiccough, shght 
delirium, and occasionally convulsions, close the scene. This affection 
IS seldom protracted beyond the seventh or eighth day, without termi- 
nating either in resolution or in death. 

Dhpwsfs.—When the inflammation is seated in the arch of the 
colon, peritoneal enteritis may simulate pleuritis or hepatitis From 
these affections it may be distinguished by the following circum- 
stances:— In pleurisy, the pulse is full, hard, and active-in enteritis. 
It is contracted, corded, quick, tense, and frequent. In pleurisy, the 
respiratory motion of the thorax is not conspicuous, the act of respira- 
tion being performed wholly by the diaphragm and the abdom^inal 
muscles -in enteritis, on the contrary, ihe chest is regularly and 
strongly dilated and contracted by the action of the intercostal mus- 
cles, whilst the abdominal muscles and the diaphragm are quiescent 
In pleurisy, the pain is aggravated by pressure on the intercostal 
spaces but abdominal pressure causes little or no suffering-in ente- 
ritis, the reverse obtains, abdominal pressure causing much ac^grava- 
tion of the pain, whilst pressure on the intercostal spaces gTves no 
particular uneasiness. 

« From simple peritonitis, enteritis diifers by the presence of vomit- 
ing, and obstinate constipation of the bowels. The pulse also is 
more permanently frequent, and the pain more violent and constant 
often resembling the tormina of ileus."* 

From spasmodic pain of the bowels, enteritis is readily distinguished 
by the following signs :— In enteritis, the patient lies quietly on his 
back, moving himself as little as possible-in colic, he throws himself 
about almost continually. In enteritis, abdominal pressure ae?ra- 
yates the pain-in colic it often relieves it. In the former afl^ection 
the pain is continuous -in the latter, it frequently intermits entirely 
for a short period. The skin, in enteritis, is hot and dry-in colic, it 
is seldom above the natural temperature, and generally moist In 
colic there is rarely any thirst— in enteritis almost always. 

It has already been stated that in the present variety of enteric in- 
flammation, the chief, and sometimes perhaps the exclusive seat of 
the disease, is in the external peritoneal covering of the intestinal 
canal, though the muscular coat, no doubt, very generally participates 
m the inflammation. In some cases, it would seem, the inflammation 
commences in the internal or mucous membrane, and after a lon^^er 
or shorter period, leaves this structure to fix itself on the muscular 
and peritoneal tunics. (Armstrong ) 

The existence of obstinate constipation in enteric inflammation 
may be regarded as a pretty certain sign that the disease is seated in 
the peritoneal and muscular coats of the bowels, or in one or the 
other of these tunics separately. Abercrombiet asserts, that in peri^ 

* Abercrombie on the Diseases of the Stomach, &c. 

t Pathological and Practical Researches on the Diseases of the Intestinal Canal 
Edinburgh, 1828. 



224 ACUTE ENTERITIS. 

toneal enteritis, the peristaltic action of the bowels is not particularly 
affected ; and that, whenever obstinate resistance to the operation of 
purgatives exists, the muscular coat is the scat of the inflammation. 
This does not entirely accord with general experience ; for, it is well 
known, that constipation is scarcely ever absent in every variety of 
peritoneal inflammation. Without doubt, inflammation of the mus- 
cular coat will always be accompanied with more or less inactivity 
of the bowels ; but the mere absence or presence of constipation 
cannot be viewed as distinctive of muscular and peritoneal inflam- 
mation in enteritis. It is, indeed, probable that peritoneal and mus- 
cular inflammation are almost always concomitant in this aflectioii ; 
and all attempts to assign appropriate symptoms to each separately, 
must be fallacious, and, indeed, of no practical usefubiess whatever. 
Nevertheless, the presence of costiveness or diarrhoea affords us a 
good diagnostic between rnucous and peritoneal, or peritonco-muscu- 
lar inflammation in enteritis. " In proportion as the force of the in- 
flammation is directed upon the peritoneal and muscular coats of the 
intestines, constipation prevails ; and, on the contrary, when irrita- 
tion or inflammation is seated in the mucous membrane, diarrhoea or 
dysentery obtains." (Dr. James Johnson.) 

Post-mortem appearances. — The only favourable termination of 
peritoneal enteritis is in resolution — and this termination is frequently 
attended by a moderate diarrhoea. Suppuration is a rare occurrence 
in this afl'ection. I have lately, however, met with an instance in 
which this termination occurred. Its most common fatal termina- 
tion is in gangrene. But it would seem from the observations of 
pathologists, that this disease sometimes terminates fatally, without 
the occurrence either of suppuration, effusion, or gangrene, or with- 
out any perceptible structural changes, (Wilson, Broussais, Aber- 
crombie,) and merely " from the general irritation and lesion of 
function." 

In some cases of extensive inflammation of the external tunic of 
the bowels, coagulable lymph is thrown out, and adhesions formed 
between the difl'erent folds of the intestinal tube, so as to agglutinate 
the bowels in some instances, into a round and firmly adherent mass. 
This mode of termination is usually accompanied by more or less of 
a sero-purulent fluid in the cavity of the abdomen, attended some 
times with masses of a fatty substance resembling soft butter, depo- 
sited in the cavities formed by the folds of the intestines — an instance 
of which occurred not long since to Dr. Hartshorn and myself 

Causes. — Peritoneal enteritis may be produced by an accumula- 
tion of indurated feces in the bowels ; by spasm; external mechanical 
injuries ; hernia ; drastic purgatives ; sudden suppression of perspira- 
tion from cold ; standing long on cold and damp ground ; metastasis 
of external inflammations, of gout — rheumatism, erysipelas, &c.; intus- 
susception, worms, wounds, &c. 

Prognosis. — This disease is always to be regarded as one of very 
considerable danger. A very contracted or scarcely perceptible pulse, 
attended with cold hands and feet: or an extensive diffusion of the 



ACUTE ENTERITIS. 225 

pain throughout the abdomen, more especially when at the same 
time, the abdomen becomes tumid, tense, elastic, and extremely tender 
to pressure, indicates great danger. Very frequent and violent vomit- 
ing is also a very unfavourable sign ; for, independent of the additional 
irritation and suffering which it causes in the inflamed, structures, it 
contributes, in no small degree, to increase the general prostration, 
and prevents, moreover, the retention of both remedial and nutritient 
articles into the stomach. Hiccough, in the early period of the dis- 
ease, is not indicative of particular imminent danger ; in the advanced 
stage it comes in the train of fatal symptoms, manifesting the super- 
vention of gangrene. An expanded state of the pulse may be re- 
garded as a favourable sign — the degree of violence and danger 
corresponding generally with the degree of contraction and obscurity 
of the pulse. After all, the prognosis in this afiection is always 
attended with much uncertainty. I have seen patients recover from 
this disease after most of the above unfavourable symptoms had 
made their appearance ; and, on the contrary, several deaths have 
occurred from this affection, in my practice, most unexpectedly, when 
no particular unfavourable symptoms were present. 

Treat metif. — In the commencement of the disease, prompt and 
efficient blood-letting is the remedy upon which our hopes of success 
must be mainly placed. The first bleeding should be carried to the 
extent of producing a decisive impression on the system. After the 
violence of the disease has been thus checked, smaller bleedings 
should be repeated from time to time, so as to keep up the impression 
made by the first. The success of medical treatment in this affection 
depends in a great measure on promptly breaking down the violence 
of the inflammation during the first twenty-four hours, and nothing 
can contribute so much to this desirable effect, at this early period 
of the complaint, as efficient blood-letting. 

Writers have expressed different opinions with regard to the utility 
of local bleeding by leeches, in this, as well as in other acute inflam- 
mations within the cavity of the abdomen. Abercrombie observes, 
that "leeches are eruitled to no confidence, except when the affection 
is limited, or the strength unable to support constitutional measures." 
In the beginning of the disease, little or no advantage will result from 
this mode of depletion, but after the violence of the inflammation has 
been subdued by decisive venesection, leeching over the seat of the 
pain is unquestionably a very important auxiliary. The removal of 
blood in this way must at least tend to sustain the antiphlogistic 
impression made by the previous general bleeding, and it may be 
practised with advantage where the propriety of further venesection 
may be doubtful. 

Pur^dtives, under proper management, are decidedly useful in 
this affection. The more drastic articles of this kind, however, 
should be avoided, as they rarely procure adequate evacuations, and 
frequently do mischief by exciting much sickness, vomiting, and 
tormina. In two instances of this disease, reported by Dr. Aber- 
crombie, a relapse was the consequence of the use of drastic purga- 
tives. He thinks himself warranted, from the results of his expe- 

VOL. I. 15 



226 ACUTE ENTERITIS. 

rience, to conclude that purgatives are apt to prove detrimental in 
the early period of enteritis, and in this opinion Dr. Johnson seems 
inclined to agree with him. In the early stage of the disease, laxa- 
tive enemata ought to be used ; and I have known considerable 
advantage derived from the copious injection of warm water, ren- 
dered slighlly mucilaginous by starch or flaxseed, into the bowels. 
Laxatives of the milder kind, when judiciously managed, are, how- 
ever, not only perfectly harmless, but generally unequivocally bene- 
ficial in this malady. But even these should not be administered 
until a stroi.g impression is made on the system by blood-letting. 
After proper depletion has been made, the intestines ought undoubt- 
edly to be evacuated by the administration of laxatives; and for this 
purpose calomel, with castor oil and opium, will generally answer 
perfectly well. Two grains of opium, with five or six grains of 
calomel, may be given every two hours. As soon as the abdominal 
pain is allayed, and the skin becomes soft, effects which almost in- 
variably follow the use of this anodyne, an ounce of castor oil should 
be given, and repeated in half ounce doses every two hours, until the 
bowels are freely evacuated. Should this plan fail to excite purging, 
enemata must be given to promote the operation of the oil. One of 
the best injections for this purpose is spirits of turpentine, mixed with 
some mucilaginous fluid. Thus : 

R.— 01. terebinth, gj. 
Vitelli ovi, No. ii. 
Infus. sem. lin. tepid, ^xvi. — M. ft. enema. 

When this is effected, another full dose of opium must be admi- 
nistered, and quietude enjoined. It is to be recollected, however, 
that the use of this valuable narcotic is to be restricted altogether to 
the advanced period of the disease, when the general and local 
inflammatory excitement has been in some degree broken down by 
sanguineous evacuations ; for at an earlier period it could hardly fail 
proving injurious. 

Nothing need be apprehended from the ordinary constipating 
effects of opium in this disease. This article, on the contrary, is in 
general the best means we possess for favouring the operation of 
purgatives in enteritis. It lessens the extreme irritability and sensi- 
bility of the inflamed intestines, and thereby prevents purgatives and 
the usual contents of the bowels from exciting them into inordinate 
contraction, the principal cause perhaps of the constipation. Drs. 
Armstrong and Johnson have done much towards removing the 
prejudices so generally entertained against the employment of opium 
in some of the phlegmasial affections. The former of these eminent 
writers states, "that his attention was drawn to this subject by 
observing a chasm or defect in the common modes of treating acute 
abdominal inflammation by the simple depletion of bleeding and 
purging. He had long observed, that when in affections of this kind 
opium was given in full doses, immediately after copious depletion, 
the cases terminated successfully. Within'the last four years I have 
prescribed large doses of opium, after adequate blood-letting, in at 



ACUTE ENTERITIS. 227 

least a hundred cases of acute and subacute inflammation in the 
abdomen, and always with obvious advantage." In acute peritoneal 
inflammation of the stomach and bowels, he makes it a rule to bleed 
in the first stage, until syncope approaches. As soon as the patient 
recovers from the faintness caused by the first bleeding, three grains 
of opium are administered and quietude enjoined. <' The effects of 
opium' thus administered are to prevent a subsequent increase in the 
force and frequency of the pulse, and a return of abdominal pain, 
while it induces a tendency to quiet sleep, and a copious perspiration 
over the whole surfiice. If in three or four hours after the opium is 
taken, there is pain on pressure in any part of the abdomen, with a 
hot and dry skin, and a quick jerking pulse, I order the patient to be 
immediately bled in the same decisive manner."* Dr. Johnson,! in 
remarking on a fatal case of enteritis, observes: ''Medical men now- 
a-days trust too exclusively to sanguineous evacuations in enteritis, 
and neglect certain and powerful auxiliaries which they would do 
well to call to their aid. If, when they have bled copiously, and as 
far as the patient's strength will bear, they will exhibit opium in 
combination with calomel, they will have the satisfaction of saving 
many lives. This has been my practice, and I know it to be the 
successful practice of one of the first hospitals of London." Schmidt- 
mann, one of the most experienced of the German physicians of the 
present day, observes, that opinm deserves to be considered as among 
the most powerful anti-enteric remedies. He particularly recom- 
mends the exhibition of this narcotic, in union with calomel, and 
asserts that since he became acquainted with the valuable powers of 
this combination, he has not found it necessary to draw so much 
blood as before.J In my own practice I have had repeated and 

* Transactions of the Associated Apothecaries and Surgeons Apothecaries, of 
England and Wales^ vol. i, art. 3. 

t In his remarks on Dr. Scott's case of fatal cystitis hepatica, (Edin. Journal, 
April,^ 1825j) Dr. Johnson uses the following language, in relation to the employ- 
ment of opium in inflammatory affections: ''We reiterate what we have often 
said before, that practitioners are too much afraid of opium in inflammations, 
especially of the abdominal viscera. Yet, after copious bleeding, there is not the 
smallest danger in its administration, especially if combined with calom.el. But 
practitioners seem, in general, to have but one idea in inflammation — depletion 
— depletion. All other considerations are absorbed in this. The pain, and its 
consequences on other organs and systems, go for nothing. Bleeding and 
purging are the catholicons. The quantity of opium should never be considered 
in such cases, but only the effect. It must be given so as to subdue pain and 
irritation, whatever may be the magnitude of the dose." — Med. Chir. Rev., July, 
1825, p. 223. 

X Dr. S. expresses himself in the following manner, in relation to the use of 
opium in this affection : 

" Ex quo hoc (connubium calomelis et opii) in usum verto in curanda enteri- 
tide non tot mihi opus est phlebotomis, quam olim, cum potens hoc reraedium 
ignorarern. 

'• Vix enteritidis curationem adgressurus essem sine opio. Et milii videtur, 



228 ACUTE ENTERITIS. 

decisive evidence of the usefulness of opium, not only in the present, 
but in many other of the phlegmasia! affections. When given in 
diseases of this kind, it ought always to be. used in large doses — from 
two to four grains after suitable evacuations, so as to allay the pain, 
and with it the general sympathetic irritations of the system. 

Blisters applied to the abdomen, after the local and general in- 
flammatory action has been in a measure subdued by venesection, 
are powerful auxiliaries in the treatment of enteritis. Fomentations, 
also, or large emollient poultices applied on the abdomen, will occa- 
sionally procure considerable advantage in this affection. Some 
writers strongly recommend lubacco injections in enteritis — (Aber- 
crombie :) and they certainly tend in no small degree to diminish the 
momentum of the circulation, and to excite alvine evacuations, effects 
which are especially desirable in this affection. From the great 
aptitude of tobacco to produce extreme relaxation and prostration, 
as well as sickness of the stomach, great caution is necessary in the 
employment of this article, lest sudden and alarming depression be 
induced. An injection of this strength may be used without appre- 
hension of mischief from i's depressing influence :* 

R. — Folor. tabaci. Qij. 

Aqua; ferventis, ^xvj. — M. The half of this will be sufficient for one 
enema. 

The ordinary internal antiphlogistic remedies, such as nitre, anti- 
mony, spiritus mindereri, &c., are not only useless, but almost always 
decidedly injurious. Digitalis may be used with advantage in the 
advanced periods of the disease, when the inflammation has nearly 
subsided, and the pulse still remains in an irritated condition — namely, 
quick, frequent, and sharp. The best way of giving this article is in 
the form of powder, of which from a quarter to half a grain may be 
given every hour or two, until its influence on the action of the heart 
is manifested in the reduction of the pulse. 

When the symptoms which are known to announce and accom- 
pany the occurrence of gangrene supervene, we should not imme- 
diately abandon all hopes of the patient's recovery, or cease our 
eflbrts to save him. In instances of this kind the exhibition of 
stimuli will occasionally speedily remove every dangerous symptom. 

idem, prsemissis pra;mittendis, inter potenlissima antienterica numerandum esse. 
Notum enim est, infiammationem irratione, procreari, atque fibras viventes ex- 
timulatas majoram exserere conatum oscillandi et se movendi: ex quo sequitur, 
in enteritide motum peristalticum augeri et accelerari; quod vomitas seepe enor- 
mis, ut plurimum cum ea conjunctura est, infiammationem actione et motu fibra- 
rum partis adfectas exasperari, eandem autem quiete et vacatione a motu deliniri 
et compesci. Cum jam opio motus intestinorum vermicularis retardetur et im- 
minuatur; ideo in enteritide ab eo princeps auxilium expectandum est: quocum 
experientia pulchre conspirat. "—Summa Observaiimum Medicarum. Auctme L. J. 
Schmidtmann. Berlin, 1821, vol. ii. p. HO. 

* This remedy is recommended by Selle.— Vide Mcdkina Clinica, p. 89. 
Berolini, 1785. 



ACUTE INFLAMMATION OF THE INTESTINAL CANAL. 229 

I attended a man during the present year, affected with acute ente- 
ritis ; on the sixth day of the disease the pain ceased, his pulse became 
extremely small and weak, and the hands and feet of an icy coldness, 
and damp, with great muscular prostration. I supposed gangrene 
had taken place— announced to the patient's friends his speedy and 
inevitable dissolution, and directed all remedial efforts to be discon- 
tinued, with the exception of the use of wine and water as freely as 
he might desire to take it. Instead of finding him dead, as I expected, 
on the following morning, he was so much better as to leave very 
little doubt of his final recovery, an event which was happily realized. 
Abercrombie has recorded a case of this disease, in which the import- 
ance of attending to this fact was strikingly illustrated.* 

Mild and mucilaginous diluents may be freely allowed, unless they 
distress the stomach, or excite sickness. 

During the period of convalescence, the patient should abstain en- 
tirely from every kind of stimulating or uidigestible food. Nothing 
but the mildest and least irritating articles of diet should be used for 
several weeks after recovery. The slightest error committed in this 
way is apt to renew the intestinal inflammation. 

After an attack of enteritis, the intestines are particularly liable to 
become much distended with flatus, giving rise to troublesome tym- 
panitic distension of the abdomen. This state of the bowels may, in 
general, be corrected by external abdominal frictions, particularly 
with the flesh-brush, and by injections of infusion of mint, with assa- 
foetida, or turpentine. Schmidtmann recommends a decoction of the 
Iceland moss with colomba root, and the extract of nux-vomica, as 
peculiarly useful to allay the morbid sensibility of the bowels, after 
the inflammation has been removed. 

2. Acute Mucous Enteritis, 

Jlcide. injlammation of the mucous membrane of the intestinal 
canal may attack either the whole of this structure, from the stomacli 
to the termination of the rectum, or only a part of it ; and the symp- 
toms by which it is manifested, are considerably diversified, according 
as its superior, middle, or inferior portions, are chiefly or exclusively 
affected. 

When the inflammation is seated in the duodcmim, the tongue is 
generally covered with a whitish fur ; the taste is bitter ; the appetite 
greatly diminished or entirely lost ; the lohnle surface of the body is 
apt to become jatnidiced ;i the urine is high-coloured and bilious ; 
there is headache : and on the external region of the duodenum, a 

* On Diseases of the Stomach, &c., p. 176. 

t Dr. James Johnson, in remarking on a case reported by Andral, jnn., observes : 
" A curious fact has in these days of diligent investigation been pretty fairly esta- 
blished, namely, that irritation or inflammation in the mucous membrane of the 
duodenum, will sometimes produce jaundice, where no obstruction can be de- 
tected in the biliary duct. This fact, we think, will ultimately throw some light 
on the nature of yellow fever." — Med. Chir. Rev., Jan. 1828. 



230 ACUTE INFLAMMATION OP THE 

shining fullness or puffiness may generally be perceived. The pain 
is not often considerable, and the bowels, though slow, may be read- 
ily moved by mild laxatives or enemata. More or less nausea and 
vomiting usually occur ; and the pulse is corded, though commonly 
fuller than in gastritis. (Broussais.) 

When the inflammation is confined to the small mfestinea, the 
tongue is coated with a white or light brown fur along the middle, 
with its edges and tip of a bright red colour ; the bowels are some- 
times loose, or are readily moved, the stools being of a mucous, or 
oleaginous character ; and the " integuments of the abdomen hard 
and tender under pressure at particular points or patches." The sto- 
mach is generally irritable ; and a continued slight burning pain, with 
a sensation of weight, is felt in the umbilical region, with occasional 
tormina. 

When the inflammation is located chieflij in the mucous membrane 
of the colon and rectum, the disease is characterized by frequent mu- 
cous and bloody stools, tormina, tenesmus, and retention of the natural 
feces, constituting 

Dysentery. 

Symptoms. — This disease is often ushered in by a sense of lassitude, 
want of appetite, nausea, bad taste in the mouth, depressed pulse, 
slight chills alternating with flushes of heat, thirst, dry skin, transient 
pains in the bowels, costiveness, and occasionally diarrhoea. Some- 
times the disease comes on suddenly with griping, mucous and bloody 
stools and tenesmus, without any premonitory symptoms ; and this is 
most apt to be the case, when it arises from causes that act immedi- 
ately on the mucous membrane of the intestines. In general, the 
fever is developed before the proper dysenteric symptoms show them- 
selves; sometimes more or less diarrhoea, with tormina, precedes the 
occurrence of febrile irritation ; and occasionally mucous and bloody 
stools with tenesmus, are the first symptoms. From the commence- 
ment of the disease, throughout its whole course, little or no feces are 
discharged spontaneously— the stools consisting entirely of intestinal 
mucus, mixed with more or less blood. Tenesmus is one of the most 
constant and characteristic attendants on this affection ; and thu vio- 
lence of this painful symptom aff'ords us a pretty accurate measure 
of the violence and degree of danger of the disease. There are often 
considerable pain and difficulty experienced in voiding urine. The 
tormina are extremely violent and distressing, particularly just before 
the urgent calls to stool are experienced ; and a constant soreness is 
felt in the abdomen. Sometimes the stools consist almost entirely of 
intestinal mucus, very little or no blood being mixed up with it. In 
most instances, however, a considerable portion of blood is discharged 
with the mucus, and in some cases the evacuations consist almost 
wholly of blood. These dysenteric discharges usually have a very 
peculiar disagreeable smell, but no fetor in the beginnit)g of the dis- 
ease ; but in the advanced period of violent and dangerous cases, they 
frequently possess a pungent and cadaverous smell ; and often ac- 



INTESTINAL CANAL. 231 

quire a corroding and sanious character. Sometimes a colliquative 
diarrhoea occurs, a few days previous to the fatal termination of the 
disease. In some instances, the heart and arteries sympathize but 
very httle with the local mucous inflammation, the febrile phenomena 
being scarcely perceptible; but much more commonly, the attending 
fever is of a high grade. In protracted and unsubdued cases, great 
prostration ensues ; the pulse becomes small, corded, and very fre- 
quent ; the countenance contracted and cadaverous ; the abdomen 
tender and elastic, and sometimes flat ; the skin harsh and shrunk ; 
the breath oflensive, and the gums tender and swollen. An apparent 
amendment occasionally occurs after these dangerous symptoms have 
come on ; but this truce generally lasts but a short time; for although 
the pulse rises and becomes better, and the tenesmus and tormina 
remit, the restlessness and anxiety increase ; the stools become liquid, 
dark, pungent, and offensive ; the countenance hippocratic ; the ex- 
tremities cold ; and the surface of the body moist and clammy. At 
first, the tongue is covered with a white fur, becoming brown, rough, 
and dry along the middle in the progress of the disease, with red and 
moist edges. In cases of a protracted, or subacute character, the 
edges and tip of the tongue usually become clean, smooth, and florid ; 
and in the chronic form of the disease, the whole surface is often 
smooth, clean, and red ; or red and granulated like raw flesh. The 
urine is always scanty and high-coloured, and sometimes of a pung- 
ent odour.* The hepatic and cutaneous functions are always in- 
active in this affection, the alvine discharges being invariably free 
from bile, and the skin obstinately dry during the active period of 
the malady. 

Causes. — Obstructed perspiration from cold, or vicissitude of at- 
mospheric temperature, is a frequent cause of mucous inflammation 
of the intestinal canal. A cold and moist autumn succeeding a warm 
and dry summer, is peculiarly favourable to the production of dysen- 
tery. Koino-miasniata have frequently an unequivocal agency in 
the production of this disease. It is doubtful, however, whether 
paludal exhalations are of themselves capable of exciting this affec- 
tion; but their influence in modifying its general character, is fre- 
quently very evident in hot and marshy countries, where the disease 
generally exhibits a mixed character, partaking both of the nature 
of bilious remitting fever and of pure dysentery. In localities of this 
kind, it is not uncommon to find intermitting fever and dysenteric 
symptoms succeed each other in alternation— several instances of 
which I have myself observed. Dysentery seems, indeed, very often 
the production of the united influence of koino-miasmata and atmo- 
spheric vicissitudes ; and hence, perhaps, the almost universal presence 

* Dr. Ferguson, in his account of the dysentery which prevailed during the 
British campaigns in Portugal and Spain, states, -'that in the aggravated form of 
the disease, there appeared one never-failing symptom, which served him as a 
guide and diagnostic. The urine was high-coloured, even green, scanty, and 
pungent;" and these phenomena he regarded as the signal for the vigorous em- 
ployment of mercury. — Med. Chir. Trans., vol. ii. 



232 ACUTE INFLAMMATION OF THE 

of torpor of the hepatic and cutaneous functions in this disease.* 1 he 
atmospheric temperature which is necessary to the production of 
miasmata, is sufficient also to excite the cutaneous exhalents to in- 
ordinate actiou ; whilst both the heat and the miasmata tend, at the 
same time to increase the biliary secretion. If, in this state of pre- 
disposition, a sudden reduction in the temperature of the air occurs, 
or if the body be exposed to the chilling effects of a humid and cool 
night air, the exhalents of the surface will be rendered torpid, the 
blood recoil from the external to the internal vessels, and the liver, 
in common with the other internal organs, becoming engorged with 
blood, will not only become further disturbed in its functions, but 
contribute directly to congestion in the portal vessels, and conse- 
quently to the rise of intestinal inflammation. 

There is a form of dysentery, called by some scorbutic dysentery, 
which appears to be the product of idio-miasmata, and atmospheric 
vicissitudes, or cold and humidity operating conjointly. Of this kind 
was the very peculiar and fatal dysentery which prevailed a few 
years ago at the Milbank penitentiary in England.t In this epidemic, 
spots or specks of a blue or livid colour appeared about the hams, 
and sometimes over the whole surface of the inferior extremities, and 
occasionally also on other parts of the body. The gums were spongy, 
soft, livid and much disposed to bleed ; and in some, the gums ulcer- 
ated, the teeth became loose, and the mucous membrane of the lips 
and mouth black, while the breath was extremely offensive. Some 
of the patients passed pure blood from the bowels; others, a fluid like 
the washings of flesh ; sometimes the stools consisted wholly of mucus 
and slime, streaked occasionally with blood ; and in some instances, 
"they contained what seemed to be lumps of flesh." Nearly all 
complained of a distressing and very peculiar feeling of "sinking," 
at the pit of the stomach. This disease was ascribed, by the com- 
mittee appointed to investigate its cause, to the constant and exclu- 
sive use of vegetable and farinaceous diet acting in conjunction with 
atmospheric inclemency. I think there are good grounds for believ- 
ing, that in addition to these causes, an atmosphere inquinated with 
the effluvia generated in crowded apartments, had no inconsiderable 
share in the production of this very peculiar affection. 

Although cold and dampness suddenly succeeding warm weather, 
may be regarded as a very common exciting cause of this disease, 
yet as great and sudden atmospheric changes frequently occur with- 
out the production of dysentery, the disease appearing extensively 

* " In every case of dysentery," says Dr. Johnson, " that has ever come within 
the range of my observation, two functions were invariably disordered from the 
very onset, and soon drew other derangements in their train. These were the 
functions of the skin and liver; or perspiration and biliary secretion. I defy any 
one, who has attentively regarded ihisdisease at the bedside, to produce a single 
instance, in which these functions were carried on in a natural manner, at any 
period of the disease." — On the Influence of Tropical Climates, vol. ii. 

t An Account of the Diseases lately prevalent at the General Penitentiary. By 
P. M. Latham, M. D. London, .1825. 



INTESTINAL CANAL. 233 

during some years, whilst in others it does not occur although equally 
variable and inclement, it would seem probable, that cold, or sudden 
variations of atmospheric temperature and humidity, must operate 
in conjunction with other general causes of an occult character, before 
the disease can become extensively prevalent. 

Among the sporadic causes of dysentery, may be mentioned the 
immoderate use of unripe fruit ; indigestible and unwholsome food ; 
and irritating articles of all kinds received into or generated in the 
bowels. Most writers mention scyhala as a frequent cause of this 
affection ; but the correctness of this opinion has of late been, with 
much justice, controverted. (J. Johnson.) Out of the very consi- 
derable number of cases of this disease which have come under my 
own observation, I do not remember more than six or seven in which 
scybala. were discharged. Dr. Cullen could certainly not have spoken 
from observation, when he declared, that " it is certain that hardened 
feces retained in the colon, are the cause of the griping, frequent 
stools and tenesmus." 

Post-mortem appearances. — The true pathological character of 
dysentery was not well understood, until within the last twenty years. 
Richter was of opinion that dysentery is of a rheumatic or catarrhal 
affection of the intestinal tube. This opinion was, indeed, formerly 
entertained by many pathologists ; it was advocated by Akenside, 
Stoll and Vogler. Recamier, (Rev. Medicale, Jan., 1S25,) alleges 
that the cause of dysentery consists in a " vitiated state of the fluids 
which stagnate in the alimentary canal ;'• i. e., the bile or the intes- 
tinal mucus, and the pancreatic juice. Inflammation of the mucous 
membrane, he says, is not primary in this affection, but secondary, 
the result of the irritating action of these fluids on the internal mem- 
brane of the intestines. Dr. Cullen considered the proximate cause 
of the disease to be '• a preternatural constriction of the colon, occa- 
sioning those spasmodic efforts which are felt in severe gripings, and 
which efforts, propagated downwards to the rectum, occasion the 
frequent mucous stools and tenesmus." It does not appear that he 
suspected the existence of mucous inflammation as the essential pa- 
thological condition of this affection. Later inquiries have shown, 
however, that an inflamed state of the mucous membrane of the 
large intestines is invariably present to a greater or less extent in the 
disease.* In some instances, inflammation and its consequences are 
found nowhere but in the colon and rectum, but frequently more or 
less phlogosis occupies the whole extent of the intestinal tract, from 
the duodenum to the rectum. But even where this is the case, the 
signs of inflammation and its effects are almost always conspicuous 
in the large intestines. When dysentery terminates fatally, in the 

* This, indeed, is contradicted by Recamier. He states, " when death takes 
place early and suddenly in dysentery, whether from the disease itself, or the 
supervention of another malady, we find no trace of inflammation in the intestinal 
canal, but only acrid tkuds, which are sometimes so irritating as to cause erysi- 
pelas in the parts with which they come in contact." — Revue Medicalc, Jan., 1825, 
p. 23. 



234 ACUTE INFLAMMATION OF THE 

early or inflammatory stage, the mucous membrane of the colon and 
rectum presents numerous red patches, somewhat elevated above the 
level of the surroundmg parts; and in some cases these elevated 
portions are covered with a number of minute vesicles — more espe- 
cially " in the disease as it appears in infants."* Dr. Cheyne, in his 
account of dissections made at the Whiteworth Hospital, Dublin, 
says : " the mucous membrane of the stomach and small intestines 
sometimes presented an inflamed appearance, which in general be- 
came more remarkable as the great intestines were approached." In 
the colon ulceration began to show itself; in the part nearest the 
small hitestines these ulcerations were superficial ; but as the bowel 
was traced downwards, they became deeper and more extensive. It 
was remarked that the last three or four inches of the rectum were 
sometimes almost entirely free from ulcerations. In the cases where 
death took place in the early stage of the disease, from the mere vio- 
lence of the fever, or from some other affection, the mucous mem- 
brane of the stomach and intestines was found more or less of a deep 
red or purple colour, soft and pulpy, with an uneven surface, not 
unfrequently rough and granulated.t In some instances considerable 
structural derangement of the liver occurs in the affection. Dr. Pres- 
ton, in his account of the dysentery which appeared in the seventy- 
ninth regiment at Limerick, in the year 1821, states that '-the liver 
was invariably deeply engaged in the disease ; it was in general con- 
siderably enlarged, and its whole structure apparently destroyed." 
That the liver is always functionally disordered in this complaint, has 
already been stated. In sporadic cases, however, organic derange- 
ment of the viscus is very rarely noticed, whilst in epidemic dysen- 
tery, particularly as it occurs in hot and insalubrious climates, this 
very frequently occurs. 

Prognosis. — When the discharges in the commencement consist 
almost entirely of blood, the disease is usually much more tractable 
than when they are composed chiefly of mucus, or mucus streaked 
with blood. Copious discharges of blood in the beginning of the 
disease are beneficial, perhaps, by lessening the congestion in the 
portal vessels. Colliquative and fetid stools, in the advanced periods 
of the disease, are indicative of much danger. A tympanitic state 
of the bowels, more especially when attended with discharges of a 
" muco-sanious fluid," is a highly unfavourable sign. The appear- 
ance of bile and the natural feces in the stools, indicates a favourable 
change. When the tormina, tenesmus, and tenderness in the abdo- 
men abate, at the same time that the skin becomes uniformly moist, 
we may regard the disease as tending towards convalescence; and 
the more certainly, if the stools assume more of a natural appear- 
ance. 

Treatment. — There are four morbid conditions present in this dis- 

* Abercrorabie, Pathological and Practical Researches on the Diseases of the 
Stomach, &c., p. 226. 

t Medical Reports, &c., by J. Cheyne, M. D. Dublin Hospital Reports, vol. iii. 
p. 29. 



INTESTINAL CANAL. 235 

ease, which point out the general indications to be pursued in its 
remedial management: namely, 1, inflammation of a greater or less 
extent of the mucous membrane of the intestinal canal ; 2, general 
irritated vascular excitement ; 3, torpor of the cutaneous exhalents ; 
and 4, disordered functions of the liver. According to these patho- 
logical conditions, the principal indications are: 1, to moderate the 
febrile reaction of the heart and arteries, where it is excessive ; 2, to 
restore the regular action of the liver and skin ; and 3, to subdue the 
local inflammation of the bowels. In estimating the relative import- 
ance and urgency of these indications, it is to be observed, that tor- 
por of the cutaneous exhalents, and hepatic derangement, are gene- 
rally antecedent to the intestinal inflammation, as well as to the 
febrile reaction. It would seem reasonable, therefore, to conclude, 
that the restoration of these functions in the early or commencing 
stage of the disease, constitutes a primary object in the treatment of 
this affection, and this is indeed confirmed by experience ; for in pro- 
portion as we succeed in the accomplishment of this purpose, so do 
we equalize the circulation, lessen the determination of the blood to 
the bowels, and subdue at once the general febrile excitement, and 
the local intestinal affection. 

As high arterial excitement is incompatible with the regular per- 
formance of these functions, and tends especially to augment and 
sustain the local intestinal inflammation, the first step in the treat- 
ment of the disease is to moderate the febrile excitement, where it is 
excessive, by blood-letting. In many instances, however, the attend- 
ing fever is so moderate as not to call for direct depletion; and epi- 
demics occur in which the fever is of a typhoid grade, and in which 
the abstraction of blood is wholly inadmissible. Whenever the pulse 
is firm and quick, or tense and frequent, blood should be drawn. 
Bleeding, however, is, upon the whole, a much less useful remedy 
in dysentery than in many of the other phlegmasia! afffections. Dr. 
O'Brien, in his account of the dysentery in Ireland in 1821, says, 
" that he very much doubts if bleeding has ever succeeded by itself; 
or if it be capable of succeeding in this disease, as it often does in 
other phlegmasial aff'ections. Blood-letting ought to be considered 
only in the light of a useful auxiliary, and as applicable, principally, 
if not solely, to the early stage of the disease." This corresponds 
with the observations of Broussais (Phleg. Chron., vol. ii, p. 20) ; 
and my own experience has satisfied me of its correctness in refer- 
ence to the dysenteries of temperate latitudes. In hot climates the 
disease is often very impetuous in its attack, and so highly inflam- 
matory, that prompt and copious bleeding aflfords almost the only 
means' for checking its violence, and preventing its rapid termination 
ii) disorganization of the liver and bowels. Dr. O'Hallaran, in the 
dysentery which prevailed at Gibraltar in 1824, a highly rapid and 
intlanunatory epidemic, bled in the onset of the disease to the extent 
of from 30 to 64 ounces at once, so as always to induce faintness. 
Dr. Armstrong, too, is a streiuious advocate for decisive blood-letting 
in violent attacks of this disease. "Let bleeding," he says, «be 
once fairly introduced in the beginning of the severer modifications 



236 ACUTE INFLAMMATION OF THE 

of dysentery, and there will be fewer fatal as well as chronic cases." 
Bleeding is, without doubt, a highly valuable remedy in the more 
inflammatory cases of this aff"ection; but it is equally true, that in the 
ordinary instances of the disease, as it prevails in the temperate lati- 
tudes, it may very frequently be properly dispensed with. When 
the attending fever is of a high grade, one or two efficient bleedings 
in the beginning of the disease, will generally moderate the tormina 
and fixed abdominal pain, and favour the beneficial operation of 
purgatives, calomel, opium and blistering; remedies upon which our 
principal reliance must be placed. 

Pin-i^alives, under judicious management, are among our most 
valuable curative means in this affection. The secretions deposited 
in the alimentary canal, appear to be highly acrid and irritatuig in 
dysentery, (Recamier,) and cannot fail to increase the violence of the 
disease, and the sufterings of the patient, when suffered to remain in 
the bowels. They should, therefore, from time to time be evacuated, 
by exhibiting the milder laxatives, throughout the whole course of 
the disease. Formerly, it was commonly supposed that purgatives 
proved serviceable chiefly by dislodging and evacuating scybalx, to 
the immediate irritation of which the disease was ascribed. The 
most active articles of this kind were accordingly employed, and 
repeated often to an injurious extent. I have already stated, that 
these hardened masses of feces are by no means very conmion, nor 
is it necessary to employ very active cathartics to remove them, 
when they do exist in the bowels. Dr. Johnson very correctly ob- 
serves, that " the search after these imaginary matters in the bowels, 
or rather the anxiety to dislodge them, has led to a cruel and injuri- 
ous system of purgation in dysentery." Our object in the employ- 
ment of aperients in this disease, is simply to evacuate the contents 
of the bowels, and the less irritation that is produced in accomplish- 
ing this object, the more beneficial, we may presume, will be the 
result. Castor oil and calomel are among our most valuable laxa- 
tives in this painful afljection. As soon as can be, after the com- 
mencement of the disease, from 10 to 12 grains of calomel should 
be administered; and followed after the lapse of three or four hours, 
by an ounce of castor oil, to which 20 or 30 drops of laudanum may 
be advantageously added. The union of anodyne and laxative re- 
medies is particularly beneficial in cases attended with much pain 
and soreness in the abdomen. In instances of this kind, the irrita- 
bility of the bowels is often so great, that even the mildest laxatives 
frequently occasion much griping and spasmodic contraction of the 
intestinal tube, in consequence of which, little or no feculent dis- 
charges are procured by their operation. Under these circumstances, 
opium, so far from impeding the operation of laxatives, contributes 
often considerably to their aperient effects, rendering the discharges 
feculent, copious, and less painful. Dr. Cheyne states, that castor oil . 
did no good in the epidemic he describes, unless it was given in con- 
junction with laudanum, when it alwaj'-s answered remarkably well. 
Calomel should always form a part of our laxative remedies in this 
disease, particularly in its early stage. This article would appear to 



INTESTINAL CANAL. 237 

be peculiarly beneficial in the dysenteries of hot climates. Dr. John- 
son (on Tropical Climates) gave it in scruple doses with the happiest 
effect, a practice which has been pursued in the southern districts of 
our own country with marked benefit. In the ordinary forms of the 
disease, as it occurs in tlie temperate, and less miasmatic latitudes, 
however, it will seldom be necessary to resort to doses of this size, 
although I should apprehend no particular disadvantage from one or 
two sucli doses in the early periods of the disease. Rhubarb was at 
one time much employed in this affection ; but its operation is always 
slow and uncertain in this disease, and generally attended with very 
severe griping. In chronic dysentery, however, rhubarb, from the 
tonic powers which it possesses, may be used occasionally with con- 
siderable advantage. Dr. Cheyne has known half an ounce of cremor 
tartar, finely levigated, and given every fourth or sixth hour, to restore 
patients to health, " who would, he thinks, have sunk under any of 
the modes of treatment in use." 

Emetics were formerly much prescribed in this disease ; and they 
deserve, in fact, much more attention in the management of this 
alTection than they appear at present to receive. Cleghorn consi- 
dered active emesis, produced by a combination of ipecacuanha and 
the cerated glass of antimony, as particularly useful in cases that 
begin like simple diarrhoea. We have also the testimony of Monro, 
Cullen, Pringle, Zimmerman and Richter, in favour of this class of 
remedies in dysentery ; and among the more recent writers who speak 
favourably of this practice, we may mention Chisholm,* Johnson, 
0'Brien,t and Cheyne. I have myself had many examples of the 
good effects of emetics in the commencement of the disease. Pringle 
and Cleghorn recommend the cerated glass of antimony. The former 
states that he has used this remedy with success, after other articles 
had failed. The harshness of its operation, however, has induced 
physicians generally to relinquish it. Chisholm thinks the sulphate 
of zinc preferable to any other article of this kind. Many practi- 
tioners prefer ipecacuanha, and indeed this article appears to me 
properly entitled to preference as an emetic in this disease. It is at 
once mild and certain in its operation, and generally causes a per- 
ceptible increase of cutaneous exhalation. But its peculiar advan- 
tages over other emetics in this disease, arise from its tendency to 
allay intestinal irritation, and of increasing, rather than impairing 
the tone of the stomach. Emetics are especially indicated when the 
tongue is coated with a brown fur along its middle, and where much 
nausea and bilious vomiting occur in the beginning of the disease. 
The usefulness of this class of remedies is, however, in a great mea- 
sure, restricted to the early part of the disease. It is not probable 
that the beneficial effects of emetics in this affection depend merely 
on their evacuant operation. The concussion which the act of vomit- 
ing causes in the abdominal visceraj excites the portal circulation, 

* A Manual of the Diseases of Tropical Climates. London, 1822. 

t Observations on the Acute and Chronic Dysentery of Ireland. Dublin, 1822. 



238 ACUTE INFLAMMATION OF THE 

which is always more or less in an engorged state in dysentery; 
promotes the activity of the hepatic function ; and finally strongly 
determines tlie circulation to the skin. 

Diaphoretics.— ^uch is the intimate relation which subsists be- 
tween the external and internal surfaces of the human body, that 
the inordinate excitement of the one is always attended with a dimi- 
nution of action in the other ; and hence, in all diseases of the intes- 
tinal canal, connected either with high irritation or inflammation, 
the skin is dry and harsh ; and hence, too, the excitation of the cuta- 
neous exhalents generally contributes greatly to the removal of such 
affections. Sudorifics have, indeed, long held a primary rank among 
the remedies for dysentery.* Some difference of opinion has been 
expressed with regard to the comparative usefulness of free sweat- 
ing, and of mere gentle diaphoresis in this affection. In general, a 
uniform moisture of the skin, will, I think, procure all the advantages 
which can be obtained from remedies directed to the skin. After 
the bowels have been adequately evacuated by mild purgatives, and 
the general arterial excitement moderated by venesection, where this 
measure is indicated by the state of the pulse, diaphoretics in con- 
junction with calomel, are valuable curative means. For this pur- 
pose, the/? tz/y/y ipecaciianhse compositus is probably the best article 
we possess. It may be given according to the following formula: 

R. — Pulv. ipec. compos, gr. xxiv. 

Submuriatis hydrarg. gr. vi. — M. Divide into six equal parts. S. Give one 
every three or four hours. 

A combination of opium and ipecacuanha also forms an excellent 
diaphoretic in this disease: from one to two grains of the latter, with 
one-fourth of a grain of the former, may be given every two or three 
hours, until diaphoresis occurs. Dr. O'Brien asserts, that a combina- 
tion of opium, calomel and James's powder, forms one of the most 
powerful anti-dysenteric remedies we possess, and Dr. Johnson con- 
curs with him in this observation. Much benefit may likewise be 
obtained from a combination of from fifteen to twenty grains of the 
powdered root of Jisclepias tnherosa, half a grain of ipecacuanha, 
and a quarter of a grain of opium, given every two or three hours. 
About seventeen years ago, while practising in Lancaster county, of 
this state, I frequently employed this combination, and the result was 
in general decidedly beneficial. The employment of diaphoretics 
should be accompanied with the free use of tepid mucilaginous 
diluents. 

Calomel, with a view to its constitutional influence, is a remedy 
of excellent powers in this disease. It may be conveniently and 
advantageously given in union with diaphoretics. Itjs unnecessary 
to cite authorities in support of the usefulness of this remedy in 

* Mosely asserts, that '' intermittents are not cured with more certainty by the 
Peruvian bark, than dysentery by sudorifics." This encomium, however, is uUra 
rem tendere. 



INTESTINAL CANAL. 239 

dysentery. Nearly all those 'who have published their experience 
in relation to this affection concur in their statements respecting the 
good effects generally derived from a greater or less degree of mercu- 
rial influence in this disease. It is, indeed, seldom necessary to excite 
ptyalism— the slightest mercurial action being generally sufficient to 
obtain its curative effects in the dysenteries of the temperate latitudes. 
In hot and insalubrious climates, the disease frequently makes its 
attack with great violence, and passes rapidly through" its course. 
The liver generally suffers prominently, and often becomes disor- 
ganized in a few days. In cases of this kind, the sooner the system 
is brought under the full influence of mercury, the greater, in general, 
will be the chance of the patient's recovery, (Ferguson, Johnson.) 

Opium was, by the authority of CuUen, for a considerable period, 
almost wholly excluded from the list of remedies proper in dysen- 
tery. Sydenham, long before, had a more correct opinion concern- 
ing the value of this narcotic in this affection. <' So important," he 
says, "is opium in the hands of a skilful physician, that without it 
his hands are, as it were, tied, and his power of doing good in dysen- 
tery greatly diminished." Dr. Stokes states that cases came before 
him, during the epidemic dysentery in Dublin, in 1818, in which the 
ordinary plan of treatment by diaphoretics, purgatives, and calomel, 
appeared to make no impression on the disease. These cases were 
attended with intolerance of the slightest pressure on the abdomen, 
agonizing pain, unceasing tenesmus, and great pyrexia, In these 
instances, opium in large doses, in conjunction with copious bleeding 
and scruple doses of calomel, often procured decided relief. " Were 
the same cases again placed under my care," he says, " I would not 
hesitate to give opium in doses of four or five grains, as it was the 
opium chiefly which seemed to me to arrest the progress of the in- 
flammation." 

It should be observed, however, that though a valuable remedy in 
this disease, opium should not be freely given in the bes^inning of 
the complaint, more especially when the febrile reaction is of a vigor- 
ous grade. In such cases, decisive blood-letting should be premised. 
But even in cases of this general phlogistic character, small doses of 
this narcotic, in conjunction with laxatives, generally afford considera- 
ble benefit. After the disease has continued for two or three days, 
more frequent doses may be given in the diaphoretic combinations 
mentioned above. As the disease advances, opiates will become 
more and more necessary ; and in the chronic form, or where the 
febrile reaction is weak, they are of primary importance. From 
what I have witnessed in a few cases, during the present season, I 
am inclined to think that the sulphate of morphia, dissolved in a 
considerable portion of some bland mucilaginous fluid, as flaxseed 
tea, or decoction of the slippery elm bark, constitutes a peculiarly 
beneficial form for administering opium in this affection. One quar- 
ter of a grain in a cup of mucilaginous liquid, may be taken every 
four, or six, or eight hours. 

The nitrous acid, in conjunction with opium and camphor, is 
strongly recommended by Dr. Hope, of Chatham. He states that he 



240 ACUTE INFLAMMATION OF THE 

has been in the habit of using this combination for more than twenty 
years, and with very marked advantage.* It may be given thus : 

R. — Acid, nitros. ^i. 

Mistur. camph. ^viij. 

Tinct. opii, gtt. 80. — M. S. Take the fourth part of this mixture every 
three or four hours. 

We are informed by Dr. Johnson, that the nitrous acid has long 
been used in India in this complaint, and generally with much ad- 
vantage.! He has himself found it very useful in chronic bowel- 
complaints succeeded by acute ones. In a single case of obstinate 
subacute dysentery, I have lately used the pyroligneous acid with 
marked success. The discharges, previous to the employment of this 
article, were very offensive — but in the course of twenty-four hours 
they were greatly improved both in appearance and smell ; and the 
patient soon began to convalesce under the employment of this 
remedy, in conjunction with small doses of Dover's powder, calomel, 
and prepared chalk. 

Sugar of lead has also been used, in union with opium, in dysen- 
teric affections. Dr. Burk, of Dublin, gave it with very excellent 
effect, according to the following formula : 

R. — Acetat. plumbi, gr. iv. 
Tinct. opii, gii. 
Aq. distillat. §ii. — M. S. Takefrom gss. to ^i. every third or fourth hour. 

In this city, opium and sugar of lead have been used by a few 
practitioners ; and, as it is alleged, with considerable advantage. 
(Dr. Harlan.) That this astringent may sometimes prove serviceable 
in the advanced periods of the disease, I have myself had convincing 
testimony. In general, however, all astringents, of whatever kind — 
but certainly, more especially vegetable astringents, are improper in 
the early stages of this complaint, and very often wholly useless, if 
not injurious, even at later periods of the disease. There may occa- 
sionally be found modifications of dysentery, in which this class of 
remedies will do much good ; and of this kind was the scorbutic 
dysentery described by Dr. Bampfield. In general, astringents ap- 
pear to be much better adapted to the management of this disease, 
as it occurs in tropical climates — especially after the mercurial action 
has been gone through, and the bowels freely evacuated by laxatives. 
When in the advanced stage the morbid secretions continue after the 
inflammatory symptoms have been subdued, astringents will some- 
times afford considerable advantage. Under such circumstances, we 
may use the decoctions of cusparia, logwood, or the root of geranium 
maculatum or of Heucrea Americana. Abercrombie says that he 
has used powdered charcoal, in combination with Dover's powder, 
with decided benefit, in a severe case of this disease. 

The hydro-chloruret of lime also deserves attention as a remedy 

* Edinburgh Medical and Surgical Journal, 1826. 

t See also Observations on the Effects of Nitric Acid and Opium in the Cure of 
Dysentery. — Med. and Phys. Jour., vol. iii. 



INTESTINAL CANAL. 241 

in this affection. According to the experience of Dr. Reed of DubHn, 
it is capable of procuring great benefit ; and it has lately been used 
in Germany, as I learn by a private communication, with very de- 
cided advantage. Dr. Reed directed a solution of ten grains of this 
salt, in two drachms of tincture of Colomba, diluted with four ounces 
of water, to be taken in half ounce doses,* 

The mix vomica was formerly much used in some parts of Europe, 
in the treatment of dysentery. Hagstrom, a Swedish physician, 
asserts that he found this article of very great service in this affec- 
tion ; and Hufeland states, that in an epidemic of this disease at Jena, 
in 1795, he obtained great benefits from this powerful narcotic. {A.\\- 
bcrt.) From one to two and a half grains of the powdered nut should 
be given every two hours, after purgatives have been effectually 
used, and the general phlogistic excitement moderated by venesec- 
tion, where it is inordinate. Schmidtmann, a German physician of 
great experience and celebrity, observes, that he has found this article 
useful in allaying the tormina, and diminishing the frequency of the 
evacuations ; but that it appeared to him to increase the violence of 
the tenesmus ; and the same observation has been made by other 
writers. Opium is a much safer and better remedy, where a narcotic 
maybe deemed proper; and to this article, accordingly, I always 
give a decided preference.t 

Tobacco also is ranked among the useful remedies in dysentery. 
Dr. O'Brien:]: employed it in the form of enemata, in the proportion 
of ten grains of the tobacco to six ounces of boiling water, and 
directed the abdomen to be fomented with an infusion of the strength 
of two ounces to two pounds of boiling water. When thus em- 
ployed, tobacco is said to moderate the action of the heart and arte- 
ries ; allay the intestinal spasm ; promote free purgation ; relieve the 
tormina and tenesmus ; and restore the free action of the cutaneous 
exhalents. 

Local bleeding by leeches is recommended by some, and it is most 
assuredly clearly indicated in this affection. It does not appear, 
however, from the testimony we have on this point, that the degree 
of advantage usually obtained from this practice, is often as great as 
one might reasonably expect. In infants or young children, leeching 
seems to be more beneficial in this disease than in adults. Neverthe- 
less, where there is much abdominal tenderness to pressure, and the 
general momentum of the circulation has been moderated by vene- 
section, great relief is sometimes obtained from thirty or forty leeches 
applied over the lower part of the abdomen. Where leeches can be 
procured, this mode of depletion ought, certainly, not to be neglected, 
especially in obstinate cases, or in such as approach to a chronic 
character. 

* Med. Chir. Rev., Jan. 1828, p. 42. 

t "Ab anno 1800," says Schmidtmann, '-'omissa nuce vomica semper unice 
opio ususfui, quod nunquam mea fefellit vota : fere semper adjunxi calomel."— 
Sum. ma Observatianum Medicarum, torn, iii, p. 202. 

X Loco Citat. 
VOL. I. — 16 



242 ACUTE INFLAMMATION OF THE 

Blisters applied to the abdomen will sometimes do considerable 
ffood in cases attended with much tenderness and pam m the abdo- 
men; but I have often known them applied without any perceptible 
advantage. From considerable experience with fomentations and 
large emollient poultices applied over the abdomen, I have been led 
to regard them of more service in this affection than vesicatories. In 
the dpenteries of children, particularly after leeching, I have derived 
much benefit from the application of an emollient poultice to the 
abdomen. - Stimulating embrocations may prove serviceable in the 
chronic form of the disease. For this purpose, a mixture of the oil 
of nionarda punctata and camphorated spirits, in the proportion of 
an ounce of the former to two ounces of the latter, forms an excel- 
lent article. Where there is much abdominal tenderness, a portion 
of laudanum may be advantageously added to this mixture. After 
frictions with articles of this kind, which should be repeated three or 
four times daily, a broad flannel roller should be tightly worn around 
the body in chronic dysentery.* 

In chronic dysentery, balsam copaiva frequently does excellent 
service. Pemberton, Johnson and Cheyne speak very favourably 
of its use in this form of the disease. I have employed it with un- 
equivocal benefit. It may be given thus : 

K. — Bals. copaiv. gss. 
Pulv. g. arab. jij. 
Sacch. albi 3iij. 
Aq. fontanae §viij. 
Tinct. opii ^i. — M. S. Take a tablespoonful every two hours. 

Dr. O'Brien, who used this article with much success in chronic 
dysentery, states, that the best mode of correcting its disagreeable 
taste, is to give it in warm milk, with which it readily mixes by 
means of sugar. In very protracted cases, unattended with much 
general febrile irritation, the spirits of turpentine occasionally proves 
decidedly beneficial. From 10 to 20 drops, suspended in some muci- 
laginous fluid, should be given every three or four hours. I have, 
in several cases, prescribed this article with complete success. Small 
doses of Dover's powder, with prepared chalk, is a very useful re- 
medy in the chronic form of the disease. From three to four grains 
of the former to ten or twelve of the latter may be given every 
three or four hours; and this combination may be beneficially em- 
ployed in conjunction with the balsam copaiva. In this state of the 
disease, considerable benefit has been derived from infusion of some 
of the vegetable astringents — particularly logwood. I have used a 
decoction of the root of geranium maculatum in milk, with very good 
effect in chronic dysentery. Abercrombie recommends a strong de- 
coction of cusparia with nitric acid and laudanum. 

Dr. J. K. Mitchell has derived signal advantage from gum water 
and blue mass in chronic dysentery. Several cases yielded to these 
remedies, after a variety of other approved modes of treatment had 

* Dewar on Dysentery. 



INTESTINAL CANAL. ' 243 

been ineffectually employed.* In the thirteenth volume of the Amer. 
Jour, of Med. Sciences, Dr. J. Young has reported a case of several 
years standing, Avhich, after nearly all the known remedies and modes 
of management for this affection had been used without permanent 
benefit, yielded, in a comparatively short time, under the employment 
of gum water, for diet and drink, together with five grains of blue 
mass every night, and an occasional full dose of Dover's powder. 
This case was under my own treatment for several months. No bene- 
fit, however, was obtained from my prescriptions. 

Anodyne and emollient enemata are almost always highly useful 
in the treatment both of acute and chronic dysentery. They are par- 
ticularly beneficial in the dysenteric affections of infants and children. 
Infusion of flaxseed — of slippery elm — of althea — or a liquid prepa- 
ration of starch, with a full dose of laudanum, should be thrown into 
the rectum two or three times daily. Injections of this kind, even 
without the anodyne, rarely fail to relieve for a time the distressing 
tormina and tenesmus; and they predispose the bowels to more free 
evacuations from the operation of purgatives. Some speak very 
favourably of injections of the infusion oi ipecacuanha in this affec- 
tion. 

During the whole course of the disease, mucilaginous drinks — such 
as solution of gum arable, flaxseed tea, infusion of slippery elm, of 
althea, or very thin preparations of arrow-root, barley-water, &c., 
should be freely allowed. The free employment of mucilaginous 
fluids is of great importance in the treatment of dysentery. From 
the commencement to the termination of the disease, liquids of this 
kind should be as copiously taken as the stomach will bear. In addi- 
tion to the mucilages just mentioned, we may also notice that which 
is obtained by decoction from the pith of sassafras. This is a very 
agreeable mucilage, rarely nauseating the stomach, and from informa- 
tion I have lately obtained, it would appear to be peculiarly beneficial 
in this and other forms of mucous inflammation of the bowels. h\ 
children, fluids of this kind should be repeatedly thrown into the rec- 
tum — a measure whijph always greatly moderates the tormenting te- 
nesmus. Every kind of solid food must be carefully avoided. Among 
the foregoing mucilaginous drinks, the infusion of slippery elm bark 
is, perhaps, the best. Along with its abundant mucilage, it possesses 
slight tonic powers — a combination of virtues which renders it par- 
ticularly useful in cases of a subacute or chronic character. One ounce 
of the bark should be infused in a pint of boiling water. Mutton 
suet dissolved in warm milk, is much recommended by some writers; 
and its effects are indeed often strikingly useful. A tablespoonful 
may be taken four or five times in the course of a day. Sir John 
Pringle speaks very favourably of yellow wax and Spanish soap 
melted together, as a remedy in dysentery. During convalescence 
from this disease, great caution should be used to avoid every kind 
of indigestible and irritating food. In general, some of the milder 
vegetable tonic astringents will contribute considerably to the speedy 

* Amer. Jour. Med. Sciences, No. 4. 



244 CHRONIC ENTERITIS. 

confirmation of health. A weak infusion of the dogwood bark, or 
of cusparia with nitric acid, is an excellent article for this purpose. 
Rice, barley, oat-meal gruel, and boiled milk, are among the most 
suitable articles of diet after the subsidence of the disease. 



Sect. VII. — Of Chronic Enteritis. 

Chronic inflammation of the mucous membrane of the bowels, 
particularly of the lower portion of the small intestines and the colon, 
is a much more common affection than seems to be generally sup- 
posed. Its symptoms are often so equivocal and obscure, that the 
disturbances which it creates in the system are frequently ascribed to 
any thing else than to a phlogosed state of the internal surface of the 
intestinal tube. Most of the cases that are usually called marasmus, 
liver complaint, and dyspepsia, consist in chronic mucous inflamma- 
tion of the bowels. In this variety of enteritis, little or no distinct 
pain is experienced in the abdomen, except when firm pressillFe is 
made on the external surface. Pain and a sense of soreness, however, 
are usually felt on coughing, sneezing, or any sudden motion that 
causes a concussion of the abdominal viscera. Connected with these 
symptoms, there are always considerable languor and weakness of the 
muscular system ; the pulse is small, weak, and sharp, or corded ; the 
hands and feet usually cold ; and slight febrile exacerbations occur 
towards evening, attended with flushed cheeks, and a burning sensa- 
tion in the palms of tVie hands and soles of the feet. After eating, 
the patient is apt to complain of more or less sharp colic pain in the 
bowels. Diarrhoea is, in many instances, a constant attendant ; and 
in some cases, diarrhoea alternates with costiveness. The appetite is 
often very variable and capricious — being sometimes voracious, and 
at others entirely gone. In the advanced period of the disease, arti- 
cles of food taken into the stomach usually create much uneasiness 
until they are evacuated by the bowels in an imperfectly digested 
state. When this occurs, the patient emaciates rapidly ; the abdomen 
in children becoming more and more tumid as the emaciation of the 
other parts of the body increases. The diarrhoeal discharges are 
usually preceded by more or less tormina; and the discharges them- 
selves vary much both in frequency and appearance. They are 
sometimes slimy, mixed with more or less feces, and small in quan- 
tity ; purulent and bloody; or abundant and watery; occasionally 
dark or whitish ; and pieces of undigested food often pass off" with 
them.* The skin is generally dry, and of a sallow or dingy hue; 

* Abercrombie states, " when the disease extends along the whole course of 
the colon, the feces generally come off in a liquid state, and in this case we may 
have the evacuations consisting sometimes of thin healthy feces, more or less 
combined with the morbid discharge ; and, at other times, we may find the mor- 
bid discharge coming off without any appearance of feculent matter. When the 
disease is in the small intestines, we seldom see the peculiar discharge uncom- 



CHRONIC ENTERITIS. 245 

sleep is interrupted and not refreshing ; the tongue is almost always 
smooth and red round the margin, with a brown streak along the 
middle.* The temper is irritable, morose, or querulous, and a feeling 
of illness and suffering is depicted in the countenance. This form 
of mucous intestinal inflammation often continues for a long time 
without destroying life, but in many instances, the body emaciates 
rapidly, great weakness ensues, the mouth and faucesbecome aphthous, 
and the patient sinks under general hectic irritation. (Abercrombie.) 
Under the head of diarrhoea, this form of intestinal inilammation 
will be again considered ; for nearly all instances of obstinate and 
protracted diarrhoea consist, in reality, of chronic mucous enteritis, 
connected, frequently, with ulcerations. 

Causes. — Chronic mucous enteritis may be the consequence of the 
acute form of the disease. It is, however, much more frequently 
the result of irritation from crude and indigestible food, and other 
irritating substances acting directly on the internal coat of the bow- 
els. The protracted influence of a cold and damp atmosphere, par- 
ticularly when aided by unwholesome and indigestible diet, is apt to 
give rise to this affection. Drastic and frequently repeated purges; 
and, in short, every thing of an irritating character admitted into the 
bowels, may produce it. 

Post-mortem appearances. — The appearances on dissection are 
very various in this as in the other varieties of gastro-intestinal in- 
flammation. Sometimes we find a number of red patches, with fun- 
goid elevations in a greater or less extent of the mucous membrane ; 
and ulcerations of different shapes and sizes almost always occur in 
some parts of this structure. Sometimes " there are extensive tracts 
of ragged ulceration alternating with fungous elevations." We 
sometimes find the internal surface of the colon, or the lower portion 
of the ileum, covered with ulcerated and indurated elevations; and 
frequently the area of a considerable portion of intestine is contracted, 
so as scarcely to admit a large-sized bougie. It is now well ascer- 
tained, that ulcers of the mucous membrane of the bowels frequently 
cicatrize ; and that such cases are not, therefore, to be regarded as 
altogether insusceptible of cure. Dr. Latham,! in his account of the 
diseases of Mil bank, relates examples of this kind ; and the observa- 
tions of Petit, (of the Hotel Dieu,) Andral,jun., and M. Billard,have 
furnished us with ample and interesting evidence of the cicatrization 
and cure of such ulcerations. M. Troillet has also related instances 
in which this important process was fully demonstrated. (Jour. Gen. 

bined. It seems either to be small in quantity, or to come off so mixed with feces 
as not to be easily distinguished. " 

* Broussais, Phleg. Chron., vol. i. 

t Dr. Latham, in his account of the Milbank epidemic, says: '-there was, 
however, one appearance not unfrequently met with in our examinations, with 
which I was not then acquainted. This was the appearance of ulcers in the mu- 
cous membrane of the intestines, in the course of their progress towards repara- 
tion." — An account of the Disease lately prevalent at the General Penitentiary. By P. 
Mare Latham, M. D., London, 1825, 8vo. p. 286. 



246 CHRONIC ENTERITIS. 

Med. and Med. Chir. Rev., July 1826, et passim.) M. Troillet, in 
giving an account of the dissection of a subject that had died of 
enteric inflammation, says : " The ulcerations were of an oval and 
round form, varying in diameter from six to ten lines, with fringed 
edges, and surrounded with a brownish circle, beyond which the 
mucous membrane was sound. They occupied the lower portion of 
the ileum. Their surfaces presented the following marks of incipient, 
advanced, and complete cicatrization. Those in the first state were 
covered with a fine pellicle, transparent even after being washed or 
scraped with the scalpel. It was in some degree movable on the 
subjacent cellular substance. In other ulcerations, where the work 
of regeneration was more advanced, the pellicle was thicker, slightly 
opaque in some parts of its surface, and amalgamated, as it were, 
with the fringed edges of the sore. In those ulcers where the cica- 
trization was nearly completed, the pellicle had acquired the thick- 
ness, the consistence, and the aspect of the common mucous mem- 
brane. In those parts where the healing process had advanced to 
the greatest degree,'the fringed condition of the edges had entirely 
disappeared ; the surrounding circle was of a faint colour, or in some 
places annihilated, and the mucous membrane was completely re- 
generated." 

Treatment. — Proper dietetic regulations are indispensable, and 
constitute, indeed, our most valuable means for combating this affec- 
tion. The diet must be of the mildest kind, " and such as leaves the 
least feculence to pass along the intestines." Liquid farinaceous 
articles, such as preparations of arrow-root, oat-meal, barley, tapioca, 
rice and sago, constitute the best nourishment in this affection. 
Boiled milk, rye-meal mush, boiled rice with sugar, and occasionally 
a poached q^s,, may also be used. Animal food, in a solid form, is 
inadmissible. These observances are indispensable to the successful 
treatment of this malady. No treatment, however judicious in other 
respects it may be, can avail, if the patient do not rigidly and perse- 
veringly abstain from all kinds of solid or irritating aliment. Hav- 
ing given directions for the regulation of the diet, a mild laxative 
should be prescribed; and for this purpose, castor oil is perhaps the 
best article we possess. Broussais rejects, unreservedly, all kinds of 
laxatives in this as well as in the other varieties of enteritis. It can 
hardly be doubted, however, that the vitiated secretions, and acrid 
results of decomposition in the bowels, will be much more apt to 
make injurious impressions on the phlogosed mucous membrane, 
when suffered to accumulate, than the occasional transient stimulus 
of castor oil, with eight or ten drops of laudanum. My own expe- 
rience at least has led me to this conclusion, although I am strongly 
impressed with the conviction, that active purgatives, and even laxa- 
tives, ^hen frequently given, are decidedly injurious. 

Leeches applied to the abdomen are among our most efficient 
means for subduing the intestinal phlogosis. They should be applied, 
from time to time, to an extent corresponding with the patient's 
strength, and activity of the pulse. Much advantage may also be 
obtained from the application of blisters to the abdomen; and, in a 



CHRONIC ENTERITIS. 247 

few instances, I have known decided benefit to be derived from pus- 
tulation with frictions of tartar emetic ointment. Wearing a flannel 
bandaged tightly round the body, sometimes proves serviceable, par- 
ticularly after leeching, or rubefacient frictions to the belly. 

Among the internal remedies most useful in this affection, are 
small doses of Dover's powder, with or without minute portions of 
calomel;"* balsam copaiva in the form of an emulsion; and spirits 
of tvrpentine.\ 

It may appear inconsistent to recommend balsam copaiva and 
spirits of turpentine in this affection, after having declared that the 
most unirritating diet is a sine qua non in its treatment, and that 
active cathartics are injurious, on account of the irritation they pro- 
duce in the phlogosed structure. 

Whatever may be the conclusions of reason on this subject, expe- 
rience, which is always our best instructor, teaches that both the 
articles in question are often decidedly beneficial in the present 
variety of intestinal phlogosis. There is nothing more extraordinary 
in this than in what is observed in the treatment of some other vari- 
eties of inflammation. In catarrhal ophthalmia, soothing appli- 
cations are undoubtedly proper ; yet the application of a weak 
solution of lunar caustic, or of small portions of precipitate ointment, 
will very frequently produce an immediate amendment in the disease, 
whilst astringent washes seldom fail to do misclrief And we may, 
moreover, observe, that we apply turpentine to the inflamed skin 
from burns or scalds, and with great, and often immediate relief. 
There is a power in some articles,.besides their general stimulant 
effects, to produce a peculiar excitement, which, in certain states of 
inflammation, is particularly salutary ; and this appears to be the case 
with the articles just mentioned in the present disease. These reme- 
dies should, however, be given in small doses; and they generally 
procure most advantage when administered in conjunction with 
mucilage, and small doses of opium or of extract of hyoscyamus. 
Dr. Grenville speaks very favourably of the employment of sulphate 
of copper in affections of this kind; and Dr. Abercrombie observes, 
that he has found this article highly useful in this disease. The dose, 
at first, is half a grain, combined with an equal quantity of opium, 
and gradually increased, if necessary, to the extent sometimes of 
three grains, with half a grain of opium, three times daily. Dr. 
Elliotson also has published cases illustrative of the good effects of 
this remedy in chronic inflammation of the mucous membrane of the 
bowels. " I had two very severe cases," he says, " in which the 

* R. — Pulv. ipecac, compos, gr. xxxii. 
I Calomel, gr. i. — M. Divide into eight equal parts. S. Take one every 

five or six hours. 

t R. — Spir. tereb..^ss. 
Vitel. ovi. 
Sacch. albi. §8S. 
Aq. fontana; §iij. 
Tinct. opii giss. — M. S. Take a teaspoonful three or four times daily. 



248 ACUTE PERITONITIS. 



quantity of blood and matter evacuated, and the wretched appear- 
ance of the countenance, rendered the existence of great disease ot 
the inner surface of the intestines probable, and which would most 
likely have proved fatal but for this remedy. Both these men reco- 
vered, after having taken the medicine about six months. ' These 
patients took the sulphate of copper with opium, in doses of three 
grains three times daily.* 

Much benefit may be obtained in this form of enteric inflamma- 
tion, from the use of .the persesquinitrate of iron. From fifteen to 
twenty drops of it may be administered twice daily, in a small por- 
tion of gum water.t The sulphate of iron also, in doses of from a 
half to two grains, twice or thrice daily, is much recommended by 
Abercrombie in this affection. In some instances, decided advantage 
has been obtained from the use of nitrate of silver ; I have prescribed 
this article in union with the extract of hyoscyamus with marked 
benefit. Haifa grain of the nitrate, with a grain of the extract, may 
be given three times daily. Abercrombie mentions borax as a use- 
ful remedy in this affection. 

I have employed a decoction of the slippery elm bark, in con- 
junction with occasional leeching, and the use of small doses of bal- 
sam copaiva, with the happiest effects in several instances of this 
disease. 



Sect. VIII. — Of Acute Peritonitis. 

Acute inflammation of the peritoneum is frequently ushered in by 
a feeling of lassitude, pain in the limbs, and slight creeping chills; 
alternating with flushes of heat. Headache, and a sense of weight 
or uneasiness in the epigastrium, are equally among the first symp- 
toms. Acute pain is often felt in some part of the abdomen, at 
the very commencement of the disease. Occasionally, however, the 
pain does not occur until the febrile reaction is established, and in 
some instances it comes on suddenly, with much violence during or 
immediately after the first sensation of chilliness. The abdominal 
pain is frequently, for a time, confined to a small space, but it gene- 
rally soon spreads throughout the whole or a greater part of the 
abdominal cavity. Pain does not, however, always occur in this 
affection. In some instances of the most aggravated character, little 
or no pain, but only slight uneasiness, is felt in the abdomen — (An- 
dral). Sometimes the abdominal pain " moves irregularly about, 
remaining for a few hours in one spot, and suddenly removing to 
another." In all instances, pressure on the external surface of the 
abdomen is extremely painful. To avoid this source of suffering, 
the patient lies on his back, with the knees and shoulders raised, in 
order to take off the tension of the abdominal muscles, and the pres- 

* Med. Chirurg. Transactions. 

t The mode of preparing the persesquinitrate of iron is given in the second 
volume of this work, in the chapter on diarrhoea. 



ACUTE PERITONITIS. 249 

snre of the bed-coverings.* The bowels are constipated, or moved 
with considerable difficulty ;t the pulse is frequent, more or less tense, 
contracted and sharp, and occasionally, though rarely, it is round and 
full. The tongue is moist, and at first covered with a thin white fur, 
the edges and raphe becoming sometimes red in the progress of the 
malady. In some instances, the stomach sympathizes strongly with 
the abdominal affection, the patient being harassed with nausea and 
vomiting in the early stage of the disease. The face is usually pale, 
exhibiting a peculiar sharpness of feature, and an expression of great 
anxiety. Constant wakefulness is very commonly present through- 
out the whole course of the disease, but delirium rarely occurs except 
towards the conclusion of fatal cases. Generally, in the course of 
from twenty-four to thirty-six hours, the abdomen becomes tumid, 
tense and elastic, from flatulent distension of the intestines, and ex- 
tremely tender. Respiration is oppressed and laborious in the latter 
period of the disease ; inspiration, especially, being short, difficult, 
and attended with an expression of pain in the countenance. The 
secretion of urine is almost invariably more or less diminished, and 
in some instances almost wholly suppressed. When the peritoneal 
coat of the bladder is the seat of inflammation, " the evacuation of 
the urine will almost uniformly be suspended," and much pain felt 
in the pelvis. The peritoneal covering of the inferior surface of the 
diaphragm is occasionally the principal or sole part of this membrane 
which is inflamed, and in this case almost constant hiccough attends 
— (Scoutteten,)J When peritonitis occurs in the puerperal state — 
constituting what is usually termed puerperal fever, (he lochia almost 
always cease to flow ; and the secretion of milk becomes arrested or 
greatly diminished. In cases of this kind, the general powers of the 
system usually sink much earlier than in cases occurring in males or 
in females not in the puerperal condition. 

Acute peritoneal inflammation is generally very rapid in its pro- 
gress. It seldom continues beyond the sixth or seventh day without 
terminating either in resolution or in death, or passing into the chronic 
or subacute state. It often terminates fatally as early as the third 
day; and Andral asserts that its progress is occasionally so rapid, 
"that only a few hours intervene between the origin of the inflam- 
mation and death," But when the inflammation assumes the sub- 
net te grade, it is frequently prolonged to the thirtieth or fortieth day 
before it proves fatal. Acute peritonitis is not particularly prone to 
terminate in gangrene. § When this occurs, the abdominal pain sud- 

* " In milk fever the abdomen is soft and not painful on pressure, the rigors 
are slight, and the pulse seldom exceeds ninety. The countenance is natural, the 
breasts are swelled, hot and tender, and all these symptoms disappear in 24 or 36 
hours." — Ryan's Manual of Midwifery. 

t " Constipation," says Dr. Johnson, " is as general a concomitant of perito- 
neal inflammation, as dysenteric purging is of inflammation of the mucous mem- 
brane of the intesthies." — 3Ied. Chir. Rev., Sept. 1820, p. 1G7. 

t Med. Chir. Rev., June, 1824, p. 199. See also, Archives Generales, &c., for 
December and February, 1824. 

^ Abercromtie. On the Diseases of the Stomaeh, p. 169. 



250 ACUTE PERITONITIS. 

denly subsides ; the pulse becomes very small, frequent, and often 
intemiittiug ; great muscnlar prostration ensues; the extremities 
become cold and clammy; and the countenance pale, hollow and 
contracted. Slight wandering delirium usually occurs at last, iu 
cases that terminate in this way. 

Causes.— Acwie peritonitis may be produced by mechanical inju- 
ries of the abdominal viscera; violent and long-continued corporeal 
exertions ; stricture of the colon and rectum ; perforation of the sto- 
mach or bowels by slow ulceration, and the consequent passage of 
the ingesta or feces into the cavity of the abdomen ; extravasation of 
blood, urine, or bile, into the peritoneal cavity ; the action of cold on 
the surface of the body, causing sudden suppression of the perspira- 
tion ; wet and cold feet ; drinking cold water while the body is in a 
free state of perspiration ; jjarturition; sudden suppression of the 
hasmorrhoidal discharge, or of the menses ; metastasis of erysipelas 
(Abercrombie) ; and of rheumatism;* and it would appear a peculiar 
contagion, to which females are liable soon after parturition. 

Post-mortem appearances. — Pathological investigations have now 
fully established the fact that the peritoneum may be violently in- 
flamed without the inflammation extending to the subjacent struc- 
tures. That portion of this membrane which covers the stomach, 
intestines and other viscera, has often been found strongly inflamed, 
and even gangrenous, while the other structures of these organs were 
perfectly sound. (Broussais, Abercrombie, Armstrong.) In some 
cases the peritoneum exhibits large patches of a deep purple, and 
occasionally even of a black colour. Strong adhesions between the 
intestines very frequently occur ; and in some instances there is more 
or less adhesion formed between the intestines and the inner surface 
of the abdominal cavity. Scoutteten found, in several instances, 
subperitoneal emphysema. Sometimes these adhesions are formed 
without the intervention of false membrane, (Scoutteten,) but much 
more frequently pseudo-membranous layers form the bond of union.t 

* Andral, jun., has related a case of peritonitis which manifestly arose from 
translated rheumatism. (Repert. Generale, &c., No. 4.) Dr. James Johnson, in 
reference to this case, observes : " We think the most sceptical pathologist will 
hardly deny that there was in this case, a transference of inflammation from the 
joints to the peritoneum." This patient was received into La Charite whilst 
labouring under acute rheumatism. Several venesections were practised. After ' 
some days the rheumatism suddenly ceased, and acute pains soon came on in 
the abdomen. The abdominal pain speedily acquired great violence, and death 
took place on the third day from the disappearance of the rheumatism in the 
joints. On dissection, strong and extensive signs of inflammation were detected 
in the peritoneum. 

t [In the No. of the Med. Chir. Review for Oct. 1844, a new term is given for 
a disease, (perityphlitis,) which recalls to my mind several cases of peritoneal 
tumours which I have seen resulting from acute inflammation. In the case of a 
young man whom I attended in 1820 with the late Dr. Physick, an attack of 
acute peritonitis terminated in the formation of a firm tumour in the right iliac 
region, and a circumscribed abscess of the inferior portion of the peritoneal cavity. 
This was followed by au irremediable obstruction. On a post mortem examina- 



ACUTE PERITONITIS. 251 

White membrauiform concretions are generally found also on differ- 
ent parts of the peritoneal surface of the stomach, liver and bowels. 
Effusion into the abdominal cavity, of a whitish fluid containing 
small flocculi of lymph, or of a reddish or yellowish fluid, almost 
always occurs. Blood has been found effused into the abdomen in 
acute peritonitis. In some cases the fluid is thick, and of a straw 
colour, " resembling diluted pus, with a very peculiar odour ;" and 
in other instances, a soft, white, sebaceous matter, resembling soft 
butter, is found deposited in the interstices formed by the convolu- 
tions of the intestines. Andral found a number of small tubercles 
between the peritoneal and mucous membranes of the bowels, some 
of which were softened down, and had burst through the peritoneum. 
In nearly all instances, a greater or less extent of the peritoneum is 
found strongly injected.* 

The occurrence of effusion, or suppuration into the abdominal 
cavity, is generally announced by a diminution of the pain and ten- 
derness of the abdomen, attended with a sense of weight and oppres- 
sion in the hypogastric region ; rigors ; coldness of the extremities ; 
a soft and feeble pulse, and sometimes slight diarrhoea. 

Treatment. — The first and most important remedial measure in 
the treatment of acute peritonitis, is Mood-letting. There is no 
inflammatory affection, in which prompt and decisive bleeding is 
more essential to success in its treatment, than the present one. No 
definite directions can be given as to the quantity of blood which it 
may be necessary to draw. The first bleeding ought to be carried to 
the extent of making a very obvious impression on the system; and 
it should be repeated as soon as the pain and febrile reaction rise 
again, if the first do not break up the violence of the disease. I 

tion a date-stone was detected in the appendix vermiformis, which gave origin to 
the inflammation of the appendix, and a prodigious eflusion of coagulating lymph 
around it. The purulent effusion which followed traveled downwards to the 
cavity of the pelvis. The late Dr. Riter, of this city, was afflicted with a large 
and very lender tumour in the same region, which followed a circumscribed 
inflammation of the peritoneum, and gave him intense trouble at every return of 
irritation, for many years, until it finally destroyed him. In a similar case from 
Pike county, and in the person of a son of Mr. Hanly, the druggist, in Lombard 
street, the same kind of tumours were dispersed, after the subsidence of peritonitis, 
by a gentle ptyalism, repeated leechings and counter-irritation. I have lately seen 
two such cases, which terminated in abscesses of the right iliac region, discharg- 
ing liquid feces. In another case, which I attended with Dr. Samuel Tucker, the 
abscess was opened posteriorly above the crest of the ileum, from which a long 
lumbricoid worm eventually came out. — Mc] 

* Dr. Lee " has most satisfactorily proved, that all the destructive febrile afl;ec- 
tions which follow parturition are invariably associated with, if not directly 
caused by inflammation of some of the textures of the womb or of its append- 
ages ; and that the type or character of the fever is probably dependent upon the 
particular tissue most involved; thus, that in inflammatory pyrexia the peritoneal 
lining is inflamed, in the congestive the muscular substance, and in the low 
typhoid, the veins of the uterus and ovaria."— ilferf. CUr. Rev., 1833, p. 59. 



252 ACUTE PERITONITIS. 

have opened a vein three times in as many hours, before a perma- 
nent impression was made on the disease. The period during which 
blood-letting may be employed with a prospect of advantage in tliis 
disease, is in general limited to the first twenty-four hours from its 
commencement ; and in many instances, a lapse of twelve hours will 
render this powerful remedy abortive, or even detrimental. When 
blood is promptly and very efficiently abstracted, soon after the in- 
flammation is developed, the disease is often prostrated at once, so as 
to yield, without much difficulty, to other suitable measures. 

After the violence of the local and general symptoms has been in 
some degree subdued by venesection, topical bleeding from the abdo- 
men with leeches, will in general contribute considerably to the fur- 
ther reduction of the peritoneal inflammation. The abstraction of 
blood by leeches is generally much more beneficial in peritonitis than 
in any other variety of abdominal inflammation, and should, indeed, 
always be resorted to, whenever leeches can be procured. After 
leeching has been employed, it will be useful to apply a large emol- 
lient poultice over the abdomen, which will keep up a moderate 
discharge of blood, for some time, from the leech-bites ; and by its 
relaxing effect tend to promote the cutaneous exhalation from the 
external abdominal surface. Instead of a poultice, cloths wrung out 
of hot water may be kept applied to the abdomen with advantage. 

As soon as the abdominal pain and tenderness are somewhat 
moderated by the means just mentioned, a stimulating purgative 
should be administered, in a dose sufficiently large to excite active 
purging. The employment of active cathartics in this disease de- 
serves to be regarded as a highly important measure. In no case 
can they be omitted without losiiig the benefit of a valuable remedy. 
In nearly all instances of peritoneal inflammation, there is consider- 
able difficulty in moving the bowels; and it generally requires strong 
doses of the most active articles of this kind to procure free evacua- 
tions. The advantages which purgatives afford in this disease, are 
usually proportionate to the activity of their operation. This does 
not accord, however, with the observations of Broussais, who affirms 
that active purging is hurtful in peritonitis, on account of the vermi- 
cular contractions which it excites in the intestines, and its consequent 
increase of the morbid sensibility of the peritoneum. Dr. Abercrom- 
bie also regards active purgation as seldom necessary, and often 
detrimental in this disease Independently, however, of the many 
authorities of the first respectability, that might be cited in favour of 
the use of active purgatives in this malady, I have too often had the 
most unequivocal evidence, in my own practice, of the decided use- 
fulness of purging in peritoneal inflammation, to admit, in my mind, 
of any doubt concerning the efficacy of this practice. Upon this 
point. Dr. Johnson makes the following judicious remarks: "In ab- 
dominal inflammation, provided the mucous tissues are not inflamed, 
purgatives excite the secreting vessels, not only of the whole inter- 
nal surface of the intestines themselves, but of the glandular organs 
whose secretory ducts open into the primae vias, and thus powerfully 
deplete locally the vascular system of the abdominal viscera. When 



ACUTE PERITONITIS. 253 

the portion of the peritoneum reflected over the intestines is inflamed, 
but where the villous coat is unaifected, I hesitate not to assert from 
personal experience, that constipation of the bowels will, in nine 
cases out of ten, be a feature of the disease ; and in such cases I 
maintain, that to excite the natural action of the mucous membrane, 
immediately after proper vascular depletion, is a very powerful means 
for checking the peritoneal inflammation; in the same way that a free 
expectoration from the mucous membrane of the bronchia relieves 
the vascular turgescence and inflammation of the parenchymatous 
structure, or pleural covering of the lungs."* By stimulating the 
mucous membrane with purgatives, we not only deplete the abdomi- 
nal vessels generally, but also strongly determine the circulation from 
the peritoneal capillaries to those of the former membrane. 

Of all our purgatives, caslor oil in union with spirits of turpen- 
iine has appeared to me the most valuable in the present affection. 
I have, in a considerable number of instances of puerperal peritonitis, 
derived signal advantage from this remedy. t I have usually pre- 
scribed it according to this formula : 

R. — 01. ricini ^ii. 

Spir. terebinth, ^vi. — M. S. Take the half at once, and the remainder in 
two hours, if purging has not commenced. 

* Med. Chir. Rev., September, 1820. 

t In one remarkable case of peritonitis, I endeavoured to procure purging by- 
means of calomel and jalap, and infusion of senna, without success for a whole 
day. The disease had acquired so great a violence that I had nearly lost all 
hopes of the patient's recovery. Finally, I ordered a mixture of two ounces of 
castor oil with six drachms of spirits of turpentine, and directed the patient to take 
a tablespoonful every half hour. After the fourth dose, purging began, and 
brought off an enormous quantity of dark-coloured and extremely offensive fecal 
matter. The patient was greatly relieved by this evacuation, and could bear 
consiilerable abdominal pressure, which before was insupportable- — in short, all 
the symptoms were strikingly mitigated. Convalescence soon ensued under the 
use of purgatives, and a large blister to the abdomen. 

Dr. Hamilton administered turpentine in a few cases, but without success. 
Blundell and Copeland also tried it, but without any marked benefit. The pro- 
fession in Dublin also have ceased to employ it. All, however, who have used 
this remedy, assert that it does no injury. — Med. Chir. Rev., 1832, p. 120. 

Dr. Dewees has recorded a case of puerperal fever which was regarded hope- 
less, after the antiphlogistic treatment had been fully employed A last recourse 
Avas had to 30 drops of turpentine every hour, the application of sinapisms to the 
legs and an ounce of mercurial ointment rubbed on the abdomen every night, 
with an enema containing one drachm of laudanum. This practice was con- 
tinued for three successive days, and the patient recovered. — Amer. Jour. Med. 
Sciences, Aug. 1828. 

Dr. Isaac A. Johnson has published six cases, in each of which he exhibited 
half an ounce of turpentine with the same quantity of castor oil every hour until 
the bowels were freely purged, and then the medicine was continued at longer 
intervals. All these cases terminated favourably. — Amer. Jour. Med. Sciences. 



254 ACUTE PERITONITIS. 

It is not always necessary, however, to resort to the use of this 
active purgative at once. In some instances, a full dose of calomel 
and jalap, or of infusion of senna, or of castor oil, will procure ade- 
quate discharges; but where these articles fail to produce the desired 
effect, the turpentine and castor oil in union, will usually bring on 
copious purging. I have used with much advantage, a mixture of 
cremor tartar and powdered jalap in this affection. This will sel- 
dom fail to produce very abundant watery discharges from the 
bowels. There are few articles which excite so copious a discharge 
from the intestinal exhalents as cremor tartar; and when given in 
union with jalap, its operation is generally prompt and active. From 
twelve to fifteen grains of the jalap to forty grains of cremor tartar, 
may be given every hour until the bowels are freely moved. Dr. 
Pring strongly recommends the use of calomel in puerperal peritoni- 
tis, in ten grain doses, every six or eight hours, " Copious stools," 
he says, "quickly followed a sudden salivation, and a favourable 
convalescence was afterwards maintained by purgatives of the 
weaker sort." 

The application of a blister to the abdomen will often do consi- 
derable good, where, after decisive blood-letting and purging, some 
tenderness on pressure remains on the inflamed parts. Leeching, if 
practicable, should, however, always be premised to vesication ; but 
neither of these local means can be resorted to with a prospect of 
much benefit, until the acute character of the disease has been sub- 
dued by prompt and copious general depletion. The blistered sur- 
face should be dressed with some application capable of keeping up 
a free discharge; and for this purpose, the mercurial oinlment is, 
perhaps, the most useful in the affection. Mercurial frictions have 
indeed, of late, been particularly recommended in the treatment of 
this disease. M. Velpeau has reported four cases (Rev. Medicale, 
Jan. 1837,) in which two drachms of mercurial ointment, applied 
by-frictions to the abdomen every two hours until the mouth became 
sore, appeared to do much good. M. Laennec also cured several 
cases of subacute peritonitis by mercurial frictions. As soon as the 
moiith became sore, the symptoms began to decline. (Rev. Medi- 
cale, Mai, ,1824.) I have met with one case in which the superven- 
tion of the mercurial action appeared to exert a strong influence in 
arresting the further progress of the disease. This was a very acute 
case. Copious venesection was practised, and large doses of calomel 
administered with castor oil as purgatives; on the third day, the 
mouth was found to be sore and the breath fetid; convalescence 
speedily ensued. 

Among the internal remedies beneficial in this disease, opivm with 
calomel deserves to be particularly mentioned. After the violence of 
the local and general symptoms has been broken down by energetic 
venesection, leeching and purging, we may, in general, resort to this 
combination with great advantage. I can speak with much confi- 
dence of the usefulness of this remedy, having, for the last ten years, 
employed it in this disease with unequivocal benefit in a considerable 
number of instances. In puerperal peritonitis especially, opium either 



ACUTE PERITONITIS. 255 

alone or in combination with calomel, is often peculiarly serviceable. 
" In puerperal fever," says Dr. Armstrong, " in which the peritoneum 
chiefly sustains the intensity of the inflammation, opium may be 
given with considerable advantage, particularly when the local pain 
and constitutional irritation are excessive ; though in that stage of 
excitement, it must not for a moment be forgotten, that bleeding and 
purging are the principal measures. When the stage of collapse 
approaches, opium may, perhaps, be accounted the primary measure, 
since the allaying of irritation is then the principal object. When- 
ever opium is administered in any species of abdominal inflamma- 
tion, the dose should he large ; for a small dose often stimulates, 
whereas a large one is a direct sedative." This narcotic may be 
very usefully administered in this affection at the same time that 
cathartics are employed ; for opium in large doses, whilst it allays 
the pain and general irritation, often manifestly promotes the opera- 
tion of purgatives in peritoneal inflammation. I have usually pre- 
scribed this article in combination with calomel, in the proportion of 
two grains of the former to three of the latter every three or four 
hours. 

Antimony and nitre are seldom admissible in this disease, on account 
of the great gastric irritability which usually prevails. Digitalis has 
been recommended as a useful article in this affection. When the 
pulse remains irritated and sharp, after the disease has been in a 
great degree subdued, digitalis in small, but frequent doses, may be 
advantageously used. One grain should be given every two or three 
hours, until the frequency and tension of the pulse are sufficiently 
moderated. Most practitioners employ this remedy in much larger 
doses than the one just mentioned ; but I have generally found the 
action of the pulse more speedily moderated when given frequently 
and in small portions, than in larger ones at longer intervals. 

When a state of collapse ensues after the inflammation has been 
overcome by the means already mentioned — an event which occa- 
sionally occurs in puerperal peritonitis — it must be counteracted by 
the employment of stimulants. Wine, the carbonate of ammonia, 
opium and camphor, and Dover's powder with quinine, are the best 
articles for this purpose. " There is a period in some cases of ab- 
dominal inflammation where the disease is just subdued, but where 
there is a kind of balance between recovery and gangrene. The 
pain will vanish ; the pulse become weak ; the vital powers appear 
to sink, and a coldness overspread the body. The symptoms are 
too often indicative of mortification ; but every experienced practi- 
tioner must have occasionally witnessed cases of recovery even from 
this alarming state. Here we must give wine; for, if gangrene have 
commenced, no harm can ensue from the remedy ; and if it have not 
commenced, the wine may happen to give a salutary stimulus to the 
nervous and vascular systems, when stagnation of the vital fluids is 
on the point of taking place, and where further evacuations would 
be instant death." — (Johnson.) 

The nourishment throughout the whole course of the disease 
should be of the mildest and weakest kind. A little thin barley or 



256 CHRONIC PERITONITIS. 

rice-water, may serve at once for food and drink. The greatest care 
must also be taken to guard the patient against taking cold diiruig the 
period of convalescence; as a renewal of the disease, in a subacute 
form, is extremely apt to occur from this and other exciting causes. 

Sect. IX.— 0/ Chronic Peritonitis. 

The approach of chronic inflammation of the peritoneum, when 
not the sequel of the acute form of the disease, is so gradual and in- 
sidious, that it seldom becomes the object of medical attention until 
incurable structural changes have taken place, or effusion into the 
cavity of the abdomen. It is only by attending to the passage of the 
acute into the chronic form, that we are enabled to give an account 
of the early symptoms of the latter. When the peritoneum becomes 
affected with the chronic inflammation, more or less uneasiness and 
tenderness are experienced in the abdomen, and when pressure is made 
externally, or the patient coughs, sneezes, or performs any sudden 
motion by which a concussion of the body is produced, a feeling of 
soreness is felt about the umbilical region. In many instances, there 
is slight pain in some part of the abdomen, which may be either con- 
tinuous or occasional. In no instance, however, is the abdominal 
pain severe, for serous membranes, in a state of chronic inflammation, 
never give rise to acute pain ; and many cases are recorded in which 
this structure was found completely disorganized from chronic inflam- 
mation, without the patient having complained of any pain whatever. 
The abdomen generally becomes fuller, and in some instances elastic, 
or more or less tympanitic. Frequently, a sense of tightness and 
pricking soreness is felt across the lower part of the abdomen, after 
fatigue from bodily exertion. " There is no tension of the skin of the 
abdomen as in the acute species; on the contrary, the skin and abdomi- 
nal muscles often sit loosely upon the peritoneum, which gives a sen- 
sation to the touch, as of a tight bandage underneath, over which 
the skin and muscles may be felt, as it were, to slide. The patient 
always complains more of tightness than of pain ; and as the tight- 
ness is much increased by any congestion in the bowels, the relief 
which he experiences from evacuating their contents leads him to 
attribute his sensations to an habitual costiveness."* 

On feeling the external surface of the abdomen, we sometimes find 
deep-seated spots of induration which are more or less tender to the 
touch. (Abercrombie.) In some instances, the patient experiences a 
sensation as if a ball were rolling about the abdomen. Broussais 
ascribes this sensation to the adhesion between the different convolu- 
tions of the intestines into a round and movable mass. Such adhe- 
sions between the coils of the intestines may be suspected, says Arm- 
strong, "by a lobulated or irregular feel of the bowels under the hand 
when passed over the abdominal integuments." The bowels in this 
affection are generally torpid. The pulse is often not perceptibly 

* Pemberton on the Viscera. 



CHRONIC PERITONITIS. 257 

affected ; except, in the advanced periods of the disease, and towards 
evening in the early stage, when it usiially becomes jerky or some- 
what accelerated, quick, and contracted. The appetite is generally 
snfficiently strong, nor is the fnnction of digestion particularly dis- 
ordered, but in some instances vomiting occasionally occms. The 
face and whole surface of the body are generally pale, with an ex- 
pression of ill health and langour in the countenance. Slight febrile 
exacerbations towards evening, with more or less oppressed respira- 
tion and cough when the patient lies horizontally on the back, and 
the appearance of oedema of the feet with paucity of urine, are pretty 
certain indications that effusion is taking place in the abdomen. The 
affection is not nnfrequently connected with disease of tlie lungs. 

Chronic peritoneal inflammation varies greatly with regard to its 
duration. It sometimes terminates in fatal disorganisation and effu- 
sion within a few months ; and cases occur which continue in a very 
slow and insidious way for many months, and even for several years, 
before the system is worn down by the general irritation it ultimately 
causes. Whether protracted or short in its course, this afiection of 
the peritoneum always terminates in more or less effusion, or suppu- 
rative secretion in the cavity of the abdomen. In truth, ascites is, 
in the majority of cases, dependent on a low degree of inflammatory 
iiritation of the peritoneum. 

Causes. — Chronic is frequently a sequel to acute peritonitis. It 
sometimes occurs as the consequence of acute mucous inflammation 
of the intestinal canal — the inflammation passing from the former 
membrane to the peritoneal covering of the bowels, 'i'his is, indeed, 
no uncommon occurrence. I have met with two instances of sub- 
acute peritonitis, which came on in consequence of dysentery; and 
one other remarkable case which supervened on acute mucous in- 
flammation of the bowels, brought on by irritating ingesta. Dr. Hodge 
of this city has given an account of a well-marked case of this kind, 
wliich was evidently produced by dysenteric inflammation.* Long- 
continued torpor and congestion of the portal system from hepatic tor- 
por or protracted constipation, are probably sometimes the cause of this 
affection. It may also be the consequence of acute or chronic inflam- 
mation of the solid viscera of the abdomen — particularly of the spleen 
and liver. Blows or injuries inflicted on the abdomen ; difficult par- 
turition ; suppression of perspiration, and of hemorrhoidal discharge ; 
metastasis of erysipelas ; cold, &c., will sometimes give rise to this 
affection. 

Post-mortem appearances. — More ox less fluid is invariably found 
effused into the cavity of the abdomen in those who die of this affec- 
tion. This fluid is commonly of a whitish or whey-like colour; some- 
times it is limpid and yellow ; and occasionally it is found of a red- 
dish appearance, with small flocculi of false membrane floating in it. 
Occasionally, though rarely, the extravasated fluid is mixed with a 
.considerable portion of blood ; and instances occur in which it ap- 
pears to consist of pure blood. (Scoutteten.) I have met with a case 

* American Journal of Medical Science, &c., April, 1829. 
VOL. I. — 17 



258 CHRONIC PERITONITIS. 

of this latter kind. The intestines are often glired together in differ- 
ent parts by the intervention of false membranous matter ; sometimes 
sacs are formed by these membraniform exudations, and the intes- 
tines, containing purulent matter or other fluids of various appear- 
ances. Occasionally the intestines are found agglutinated into one 
mass, " and partly covered with thickened and adherent momentum." 
(Broussais ) 

Thickening- of the peritoneum is a very common post-mortem 
phenomenon in this affection. In some instances, this membrane, 
though thickened and otherwise disorganized, is but little injected or 
red ; in other cases, it is found reddish and highly injected. Very 
frequently the surface of the peritoneum is covered with innumerable 
small white granulations of a tubercular character.* Bayle states, 
that in a subject he examined, where these tubercular depositions 
were very abundant, he could easily scrape them off with a scalpel; 
and where this was done, the peritoneum underneath appeared per- 
fectly sound. In some instances, the peritoneum is considerably 
thickened by granular depositions between its two layers. (Gasc,t 
Broussais, Abercrombie,t Pemberton.) The mesenteric glands are 
usually enlarged and indurated. 

Treatment. — Chronic peritonitis might, perhaps, be generally 
removed, if it could be subjected to remedial treatment during its 
incipient or early period. Such, however, are the obscurity and un- 
certainty of its early phenomena, that it rarely becomes an object of 
medical attention until it has proceeded to an extent which renders 
the most judicious treatment almost invariably abortive. Broussais, 
indeed, for a considerable time regarded this affection as wholly be- 
yond the reach of remedial management. Subsequent experience, 
however, convinced him that if proper remedies are applied during 
the first twenty or thirty days of the disease, it may sometimes be 
effectually subdued, and he thinks it possible that it may yield even 
at a much later period of its course. This writer accounts for the 
great difficulty of curing this form of peritoneal inflammation, by 
referring it to the impossibility of producing the absorption of the 
tubercular matter which is so constantly deposited between the layers 
of the peritoneum, and which therefore keeps up a continued irri- 
tation in this membrane. External irritating and depleting applica- 
tions to the abdomen, constitute our most efficient means for com- 
bating this affection. Leeching is decidedly indicated, and often, no 
doubt, contributes considerably to the removal of the disease, where 
disorganization or effusion has not yet occurred. After local deple- 

* " It is always difficult, and frequently impossible," says Dr. Armstrong, "to 
predicate that tubercles exist on the serous membrane of the abdomen. But 
when the skin assumes a delicate hue — when the conjunctiva is blanched — when 
the expression of the face is more softened and pensive than natural, and espe- 
cially when the patient has any cough, a presumption of their existence might be. 
excited." 

t Dictionnaire des Sciences Medicates, vol. xl. 

X Edinburgh Medical and Surgical Journal; No. Ixiii. 



CHRONIC PERITONITIS. 259 

tion, a large blister should be .applied over the abdomen, and kept 
discharging by dressing it with mercurial ointment. From several 
instances which have lately come under my notice, I am inclined to 
regard pnstulation, by means of tartar emetic ointment, more effica- 
cious than blistering. We may also use stimulating frictions, followed 
by emollient applications to the abdomen, with a prospect of advan- 
tage; more especially where the general system is in too irritable a 
state to admit the more irritating applications just mentioned. The 
application of moxa to the abdomen has never, I believe, been recom- 
mended in the treatment of this affection. From its known power- 
ful influence in subduing deep-seated inflammations, it is not im- 
probable that considerable and prompt benefit might be derived from 
this application in the present affection. The warm bath has also 
been recommended as a useful auxiliary in the treatment of this dis- 
ease. Within the last few years, frictions with mercurial ointment 
have been used with success in this afiiection, by Velpeau and Laen- 
nec ; and from the accounts which they have published, this remedy 
would seem to be entitled to very great consideration. The latter 
writer has reported seven cases of chronic and stibacitle peritonitis 
which yielded to mercurial frictions. Two drachms of the ointment 
should be rubbed in every two hours, until the gums become slightly 
affected. Since the publication of the first edition of this work, I 
have witnessed the good effects of this practice in a well-marked case 
of this variety of peritonitis. The disease had continued several 
months before I prescribed for the patient. The abdomen was en-^ 
larged, very tense, and extremely tender to the touch. A course of 
mercurial frictions over the abdomen, together with one of the fol- 
lowing pills* at night, had the effect of gradually subduing the dis- 
ease, and restoring the patient's health. Diuretics also are strongly 
recommended in the treatment of this disease, but they can be re- 
garded only as auxiliary to the more direct and efficient applications 
already mentioned. Broussais advises the use of diuretic articles in 
the way of frictions on the abdomen. The tincture of cantharides, 
or of squills, may answer for this purpose. If any advantage is to 
be derived from this class of remedies, however, it will probably be 
better to exhibit them by the mouth, whilst other more efficacious 
applications are made to the abdomen. Dr. James Johnson recom- 
mends the following combination as a particularly powerful and 
useful diuretic, in the present, as well as in other affections : 
K. — Acicli tartarici 9i. 

Sodae carboni, gr. xxiv. 

Infus. digitalis, fi. ^ss. 

Spir. aetheris nitrici, fl. 3i. 

Tinct. scillse, M. iv. 

Aq. menthaj ,^ij. — M. ft. This dose to be taken twice or thrice daily. 

Mild laxatives must from time to time be used, so as to obviate 

* li. — Massac, hydrarg. gr. xxx. 
G. aloes, gr. x. 
Tart, antimonii; gr. i. — M. Divide into ten pills. 



260 ACUTE HEPATITIS. 

costiveness and consequent irritation from fhis source. Castor oil, 
or the acetate of potash, and crenior tartar, will commonly answer 
well for this pnrpose. Although active, purgatives are not among 
the means generally recommended in this disease, 1 have m a few 
instances known decided benefit to result from the employment of 
the following mixture. 

R. — Crem. tartar .^iss. 
Pulv. scillae gi. 
Pulv. sulphat. potass, gij. 
• Tart. Antimonii, gr. ij. — M. ft. S. Take ^ss. three or four times daily. 

This combination produces copious watery discharges from the 
bowels, and stimulates the kidneys to increased action. 

To allay the general irritation which is apt to occur in this disease, 
we may give small doses of Dover's powder, or full doses of extract 
of liyoscyamus, or of conium maculatum. From the diaphoretic 
tendency of the first of these articles, it deserves, I think, a preference 
i!i this affection. It is of great importance" in the management of this 
disease, to restrict the patient to the weakest and mildest articles of 
nourishment. Dr. Johnson observes, in reference to the possibility of 
procuring the absorption of the tubercular matter deposited in the 
peritoneum in this disease : " There can be little doubt that the ab- 
sorbents might be made to act upon many extraneous and morbid 
growths in the human body, by rigid abstinence alone, if patients 
had fortitude to persevere in the measure. For our own parts, we 
"should place more confidence in this than in any other remedy; and 
practitioners should at all times bear in mind, that without strict 
abstemiousness, there is liitle hope of a cure in chronic peritonitis." 
— (Med. Chir. Rev., Sept., 1820.) May we not expect some advan- 
tage from iodine, in the form of frictions on the abdomen, in this 
aflection ? It appears to me worthy of trial. 



Sect. X. — Of Jlcute Hepatitis. 

Although not a very frequent disease in the temperate and colder 
latitudes, hepatitis is one of the most common maladies engendered 
by the intiuence of an intertropical or hot climate. The acute form 
of this disease often makes its attack suddenly, and with great vehe- 
mence, particularly in those parts where it prevails endemically ; as 
along the sandy coast of Coromandel, and the marshy districts of 
Bengal. When the invasion occurs thus suddenly and violently, the 
patient is seized, without scarcely any previous symptoms of indis- 
position, with pain in the right liypochondrium, accompanied with a 
sensation of tightness across the abdomen; difficult respiration; and 
an inability to continue in the recumbent position ; the patient feeling 
easiest when in a sitting posture with the body inclined forwards. 
This mode of attack is frequently observed in the intertropical regions. 
In the temperate latitudes it usually comes on in a more gradual and 
less impetuous manner. The patient complains of a feeling of tight- 



ACUTE HEPATITIS. 261 

ness in the right hypochondrium and epigastric region, with slight 
incipient febrile symptoms, for a considerable time before the true 
character of the disease becomes obvious. The pain attending acute 
inflammation of the liver, is apt to extend itself from parts remote 
from this organ, more especially to the breast and to the clavicle and 
shoulder of the ris^hf, and sometimes the left side. In some in- 
stances these sympathetic pains are even more severe than those 
experienced in the liver itself Mr, Annesley observes, that when 
the internal structure of the liver is the seat of the inflammation, tho 
pain is generally heavy and aching; but when the surfaces or the 
ligaments become affected, it is usually acute, tensive and pungent. 
Pressure on the right hypochondrium always greatly aggravates the 
pain in that part; and a sihriilar effect is almost invariably produced 
by an attempt to lie on the left side ; although in some instances the 
reverse obtains, the patient feeling 77^05/ ease when recumbent on the 
left side. A dry and troublesome cough, with more or less difficulty 
of breathing, are common attendants on this disease. When these 
symptoms are connected with pain in the thorax, the disease may 
be readily mistaken for pneumonia. Nausea and bilious vomiting 
frequently occur in acute hepatitis, and in general, the severer these 
symptoms are, the less cough and difficulty of respiration will be 
experienced by the patient. In many instances, there is a distressing 
"feeling of anxiety at the epigastrium and prascordia, accompanied 
with frequent deep sighing, particularly when pressure is made simul- 
taneously on the right hypochondrium, and under the right shoulder- 
blade." A more or less jaundiced hue of the white of the eyes, and 
skin about the breast, face and neck, is one of the most constant 
phenomena of this disease. — (Louis.)* The urine, also, is invariably 
highly imbued with bile, exhibiting a deep yellowish-brown colour. 

The thirst is usually very urgent, and the skin hot and dry. The 
pulse is generally full, active and firm; but in some instances it is 
small, tense and quick : and this is said to be the case when the 
concave surface of the liver is the seat of the inflammation, and the 
peritoneal surface of the stomach or colon participates in the inflam- 
mation. The tongue is coated with a white or thick yellowish fur, 
and the taste is often bitter; or, " it is smooth and glossy, marked by 
fissures, and lobulated." (Annesley.) 

In general, the bowels are costive; yet, in hot climates, diarrhoea 
often attends from the beginning of the malady. (Chisholm.) Cases 
of this kind generally commence like dysentery. The patient is 
seized with violent griping, followed soon by small watery or slimy 
discharges from the bowels, accompanied with soreness at the pit of 
the stomach, or of the right side. If pressure is made on the right 
hypochondrium, the patient shrinks from the touch ; yet the pain in 
this part is seldom violent. " The degree of violence of the bowel 
affection," says Dr. Johnson, " will very generally indicate the degree 

* Mr. Annesley states, that jaundice is not a frequent concomitant of hepatitis 
ia India, unless the ducts or gall-bladder become involved in the disease, or when 
it supervenes to biliary calculi, or other obstructions of the ducts. 



262 ACUTE HEPATITIS. 

of rapidity and danger of the hepatic inflammation. A scalding sen- 
sation in making urine almost always occurs ; and the brain often 
sympathizes strongly with the liver in this affection, giving rise to 
more or less mental disturbance." 

Acute hepatitis rarely continues beyond the sixth or seventh day, 
without tending either to resolution or suppuration. When the latter 
has taken place, the pain becomes moderated ; the patient experi- 
ences a sense of weight and throbbing in the region of the liver, with 
irregular rigors; more or less profuse night sweats; a sense of sink- 
ing, with anxiety and oppression in the praecordia; a clammy skin; 
and a sense of formication. In some cases, " nearly the whole of the 
right lobe becomes one enormous abscess." Sometimes adhesions 
take place between the parts surrounding the hepatic abscess and the 
internal surface of the abdomen; and when this occurs, and the 
abscess points outwards, the pus may be discharged by puncture or 
incision, and the patient often cured. When the abscess is about 
pointing externally, the general fullness, distension and pain in the 
region of the liver and epigastrium, which occur before the suppu- 
rative process commences, are at first somewhat increased; but as 
the suppuration goes on, and the matter proceeds outwardly, a soft 
and more or less circumscribed tumour makes its appearance, whilst 
the general fullness and tenderness in the right hypochondrium in a 
great measure subside. " When the abscess advances beneath the 
false ribs, or near the epigastric region, it is generally sufficiently per- 
ceptible ; but when it points higher up, or more posteriorly, so as to 
come beneath the ribs, then the bulging out of the hypochondrium is 
merely marked with fullness of the intercostal spaces, and pain and 
soreness limited almost entirely to one spot. In a great majority of 
hepatic abscesses, the direction is to the exterior and superior surface 
of the liver, and hence the communication so frequent with the dia- 
phragm and lungs when they fail in pointing more externally." (An- 
nesley.) Sometimes the liver forms adhesions with the colon, or some 
other portion of the intestmal canal, and the abscess bursting into it, 
the pus is discharged by stool. Dr. Saunders thinks it probable, that 
the matter formed in the substance of the liver, may sometimes pass 
into the bowels through the biliary ducts. When adhesions form 
between the liver and diaphragm, the abscess may burst into the 
cavity of the thorax, or into the pulmonary cells, in which latter case 
it is often brought up copiously by expectoration. Dr. Wilson* ob- 
serves, that there is perhaps no instance of recovery after this accident; 
an observation, however, which has been abundantly contradicted by 
the experience of others. I have seen an instance in which an enor- 
mous quantity of thin reddish pus was discharged from an hepatic 
abscess through the lungs, followed by a perfect recovery of the 
patient's health. Annesley mentions cases of this kind ;t and Schmidt- 
mannj relates two instances of a similar character and successful ter- 

* On Febrile Diseases. 

t Loco citat. 

X Summa Obeervationum Medicarum, vol. ii. 



ACUTE HEPATITIS. 263 

niinatiou.* Purulent expectoration sometimes attends hepatitis, from 
the inflammation extending to the mucous membrane of the bron- 
chial tubes, or to the substance of the kmgs, without any direct com- 
munication between the abscess in tiie liver and the cavity of the 
thorax. Cases occur, in which the hepatic abscess bursts in the 
cavity of the abdomen ; these are almost necessarily fatal. It has 
been doubted whether an abscess containing laudable pus can be 
formed in the parenchymatous structure of the liver. Louis states, 
that by far the greater number of abscesses which occur in the proper 
substance of the liver do not contain genuine pus, but a fluid less 
homogeneous, containing small flakes of blood of a darkish gray 
colour, or like the washings of flesh. In 430 dissections, he found 
but five instances of purulent abscess in the substance of tlie liver, 
and not one in its coverings. When genuine pus is formed in hepa- 
titis, the abscess probably occurs in the cellular membrane, between 
the peritoneal covering and the glandular structure of the liver.t 

Gauf^reyie also, though very rarely, occurs in hepatic inflamma- 
tion. (Bichat.) Annesley, however, seems to doubt whether this 
mode of termination ever takes place in hepatitis. He states that he 
never met with an instance of this kind, although his opportunities 
for observation were very ample. 

In some instances, the disease terminates in a softening of the struc- 
ture of the liver. Annesley sometimes found the surface of this viscus 
"marked with red, brown, brick-coloured, greenish-brown, and even 
with almost black spots and streaks, while the internal structure was 
inflamed, congested with blood, much tumefied, and softer than na- 
tural." Abercrombie found the parenchyma of the liver soft, broken 
down, and nearly of a black colour.l 

It is supposed by Dr. Saunders,§ that in the acute variety of this 
disease, the capillaries of the hepatic artery are exclusively impli- 
cated in the inflammation ; and that in the chronic form the inflam- 
mation exists in the extreme branches of the vena portse. The same 
opinion is expressed by Professor Puchelt;l| and VVinslow ascribes 
both varieties to an inflamed state of the vena portse. There is cer- 
tainly no good reason why the capillaries of the vena portae may 
not become the seat of inflammation ; and when we take into con- 
sideration the peculiarity of the hepatic circulation, the opinion of 
Dr. Saunders is not without considerable plausibility. 

Diagnosis. — Pain in the right clavicle and shoulder has generally ' 

* Louis asserts, that abscesses in the liver are incurable ; for in all his exami- 
nations he never found a single instance of cicatrization in the liver. Dr. John- 
eon remarks, upon this assertion, " that those who have practised in India know 
that abscesses of the liver will heal occasionally, whether they are opened Exter- 
nally, or make their way into the intestines." — Med. Chir. Revj^ Janiuiry, 1827. 

t Memoir on Abscesses of the Liver. By M. Louis. — Repertoire Med., No. ii., 
1826. 

t Pathological and Practical Researches, &c. &c. Edinburgh, 1828. 

<) On the Liver. 

II Ueber das Venen System, &c. Leipsic, 1815. 



2G4 ACUTE HEPATITIS. 

been regarded as one of the most characteristic phcnonnena of hepa- 
titis. This symptom, however, is much less common than is gene- 
rally supposed. M. Louis* doubts whether it is really indicative of 
hepatic inflammation, and thinks it arises usually from some affection 
of the lungs or pleura. Upon this subject Mr. Annesley observes: 
'•The pain sometimes complained of at the top of the right shoulder, 
and so improperly stated as being one of the chief signs of hepatitis, 
is, when present, certainly characteristic of the disease in the right 
lobe; but unfortunately this symptom is only occasionally present ; 
and the inexperienced practitioner, who has been taught to look to 
this as a distinctive mark of the disease, infers, when it is not ob- 
served, thai the liver is sound. "t 

Hepatitis may be distinguished from pneumonic inflammation, by 
the following diagnostic circumstances. In ple^tritis, the cough and 
oppression in the chest are much severer than in hepalitis. In the 
latter afiection, the patient rests easiest when lying on the affected 
side; in the former, the reverse obtains. In hepatitis, pressure on 
the right hypochondrium greatly aggravates the pain, whilst pres- 
sure on the intercostal spaces produces little or no increase of suffer- 
ing; in pleuritis, the former does not, but the latter does increase the 
pain. When the substance of the lungs is inflamed, the difficulty of 
breathing and the pain are aggravated by lying on the sound side, as 
in hepatitis ; but in the former affection, respiration is performed 
chiefly by the action of the abdominal muscles and the diaphragm; 
whereas, in the latter, (hepatitis.) breathing is effected almost entirely 
by the action of the intercostal muscles — the chest being sensibly 
dilated and collapsed by the act of respiration, whilst the abdominal 
muscles are quiescent. The pneumonic symptoms are always most 
conspicuous when the convex surface of the liver is inflamed. 

The diagnosis between hepatitis and inflammation of the stomach 
is rarely attended with any difficulty. The latter affection is almost 
invariably attended with a very contracted and weak pulse, whilst 
in the former it is generally moderately full and hard. In gastritis, 
great muscular prostration usually attends from the commencement 
of the disease, and every thing taken into the stomach is commonly 
almost immediately rejected ; in hepatitis, the strength is at first not 
much impaired, and although frequent vomiting may occur, it is not 
so readily excited by ingesta as in gastritis. In the former, pressure 
on the right hypochondrium — in the latter, pressure of the epigastric 
region, causes most pain. From the pain produced by the passage 
of biliary concretions through the gall-ducts, or by spasm of these 
passages, hepatitis is distinguished by the absence of fever in the 
former, the pulse rarely rising above 90 beats in a minute, and the 
heat of the skin being but little or not at all raised above the healthy 
standard. In spasm, or irritation by biliary concretions of the gall- 
ducts, the pain often intermits for a time ; in hepatitis, it is continu- 

* Repertoire Med., No. ii., 1826. 

t Researches into the Causes, Nature and Treatment of the Diseases of India, 
&c. By James Annesley, Esq. 



ACUTE HEPATITIS. 265 

ous. In (he former affection, the easiest posture is when the body is 
bent forward on the pelvis; in hepatitis, the patient leans a little to 
the right side, with the knees slightly drawn up. When the inflam- 
mation is confined to the peritoneal covering of the liver, there is 
always more pain and fever than wiien the glandular structure of this 
organ is the seat of the disease. (Abercrombie.) 

Causes. — Br. Saunders and others describe the frequent occurrence 
of hepatitis in hot climates, to the prevalence of a peculiar miasm in 
these regions. There can, indeed, exist but little doubt, that koino- 
miasmata often contribute materially to the production of this dis- 
ease ; but their agency is probably rather predisposing than exciting, 
in relation to this affection. Miasmata unquestionably possess an 
especial power to derange the biliary functions; and it may be rea- 
sonably presumed, that where, from the general prevalence of this 
cause, in conjunction with high atmospheric heat, the liver is in an 
habitual state of morbid excitation or functional derangement; every 
adventitious exciting cause— such as the sudden influence of a cool 
and damp night air ; errors in diet, and consequent gastric derange- 
ment; the intemperate use of spirituous liquors, &c., would be pecu- 
liarly apt to develop inflammation in the biliary organs. Dr. James 
Johnson has advanced some novel and very plausible sentiments in 
relation to the etiology of this disease. He observes, that " between 
the extreme vessels of the vena portarum in the liver, and those on 
the surface of the body — in other words, between the biliary secre- 
tion and the perspiration, there exists one of the strongest sympathies 
in the human frame ; and that, whatever increases or decreases the 
action of the cutaneous exlialents, increases or decreases also the 
secretion of bile in the liver. Knowing, therefore, as we do, how 
uniformly high atmospheric temperature excites excessive perspira- 
tion, we cannot be at a loss to account for the frequency of hepatitis 
in hot climates. The excessive and continued perspiration occasions 
a loss of tone in the extreme vessels of the surface; and this loss of 
tone in the capillaries of the skin, is accompanied by a corresponding 
loss of tone in the secretory vessels of the liver. As, however, the 
perspiratory vessels, from their excessive and long-continued action, 
become debilitated and extremely sensible to the slightest degree of 
cold, so when the temperature of the atmosphere is suddenly reduced, 
as is generally the case in hot climates during the night, when the 
dew falls, the extreme vessels of the surface are instantly struck tor- 
pid, which, in consequence of the sympathy just mentioned, is imme- 
diately followed by a similar torpor of the secretory vessels of the 
liver. The perspiration and biliary secretion being, therefore, thus 
simultaneously arrested, and the passage of the blood through the 
liver obstructed, a commotion is raised, which, as there already exists 
a congestion in the portal circle, falls mainly upon that system, and 
gives rise to inflammation." That there exists a strong sympathy 
between the liver and the skin, is strikingly illustrated by the fact, 
that in chronic hepatic inflammation, or in torpor, or scirrhus of this 
organ, the skin is always dry and harsh— it being nearly impossible 



£66 ACUTE HEPATITIS. 

in these affections to excite a perceptible general exhalation from the 
surface. 1 • • 

It appears to me, nevertheless, that the influence of malaria is too 
much overlooked in this sympathetic doctrine. High and continued 
atmospheric heat is so universally attended with the extrication of 
miasmata, that it would seem extremely difficult to say how much 
of the previous hepatic excitation, and consequent atony, is to be 
ascribed to the one or the other of these causes. That a very con- 
siderable share of the effect in question is to be placed to the account 
of malaria, seems to be demonstrated by the fact, that bilious and 
hepatic aff"ections are far from being common on board of ships cruis- 
ing in tropical seas, and where the materials for miasmatic exhala- 
tions are absent; although the influence of atmospheric heat is con- 
stant and great. 

Besides the exciting causes just mentioned, there are many others 
of a less general character, capable of giving rise to this affection. 
Violent and fatiguing exercise ; contusions of the right hypochon- 
drium ; metastasis of gout* and rheumatism ; wounds and injuries 
of the cranium ;t atmospheric vicissitudes ; a draught of cold water 
while the body is in a state of free perspiration ; irritation from 
biliary concretions in the gall-ducts ; suppression of haemorrhoids ; 
violent rage ; terror ;t and mental despondency, § &c., may all give 
rise to acute inflammation of the liver. Hepatitis may be excited in 
children by the irritation of dentition, jj 

Treatment. — In this disease, as in other inflammatory affections, 
the abstraction of blood is a primary remedy. There are two rea- 
sons for resorting to decisive blood-letting in the commencement pf 
this affection — namely, the necessity of promptly lessening the gene- 
ral momentum of the circulation, as well as the congestion in the 
liver and portal vessels ; and the importance of subduing the general 
phlogistic condition as early as practicable, in order to favour the 
effects of mercurial remedies, upon the prompt influence of which 
much of our reliance must be placed. (Johnson.) As soon as blood 

*' Quantis implicetur, says Schmidtmann, periculis hepatitis ex podagra retro- 
pulsa subnata lugubri illustris Augusti Gottl. Ricliter, praeceptoris mei summe 
colendi interitu probatur; qui quippe ex podagra hepar petente et inflammante, 
annum agens septuagesimum, post paucos ab invasione dies occubuit. — Obscrv. 
3Iedicar., torn. ii. p. 231. 

t Louis doubts this : — ^The rise, however, of hepatic inflammation and ab- 
scesses from this cause, is well established by the testimony of many observers. 
See the Memoirs of M. Bertrandi and M. AndouiUe, in the Memoires de I'Acad. 
Roy. de Chirurg., torn. iii. p. 439. 

$ Schmidtmann mentions an instance of hepatitis caused by ^terror: "Jam 
memoravi me deprehendisse, hepatitidem terrore esse excitatam." — Summa. Obs. 
Med., vol. ii. p. 197. Hippocrates speaks of terror as an exciting cause of this 
affection: De internis adfectionibus. Sect, iii. cap. 1. 

4 A very striking and interesting case of this kind is related in the Annuaire 
Medico-Chirurgicale for 1822. ', . ' 

II Hufeland's Journal der Pract. Heilkunde, vol. xviii. p, 62. 



ACUTE HEPATITIS. 267 

has been drawn to an extent sufficient to make a manifest impres- 
sion on the system, an active mercurial cathartic must be adminis- 
tered. From fifteen to twenty grains of calomel, followed in about 
two hours by a full dose of castor oil, or of infusion of senna and 
manna, constitute an appropriate and efficient purgative in this dis- 
ease. It is often necessary to repeat the bleeding several times in 
the course of the first few days, before the arterial reaction becomes 
permanently moderated ; and this is particularly apt to be the case 
in the disease as it occurs in temperate latitudes. In warm climates, 
a frequent repetition of venesection is not often necessary or even 
proper — one or two efficient bleedings in the commencement of the 
disease being in general sufficient to bring down the febrile reaction. 

The application of leeches to the epigastric and hypochondriac 
regions, will often contribute very materially to the reduction of the 
hepatic inflammation ; but one or two efficient bleedings from the 
arm should be premised to the local abstraction of blood. It may 
be necessary to reapply the leeches, where, after the adoption of the 
measures just indicated, the pulse still retains some activity, and the 
local symptoms are not considerably relieved. 

The bowels should be kept in a loose state throughout the whole 
course of the disease ; and calomel must always constitute a princi- 
pal ingredient in the purgatives employed. From eight to twelve 
grains of this preparation may be given at first, every six hours, and 
followed by the exhibition of a small dose of Epsom or Glauber's 
salts; or of castor oil, or infusion of senna and manna, if after ten or 
twelve hours the calomel do not procure free evacuations. After 
the general arterial reaction has been moderated by direct and local 
depletion, and the bowels well evacuated, our principal dependence 
should be placed on the speedy induction of modern ptyalism, in 
conjunction with blisters applied over the region of the liver, and 
moderate purgation. The practice of giving opium with calomel in 
this aftection, particularly after the violence of the phlogistic excite- 
ment has been broken down by venesection, was long ago recom- 
mended as decidedly beneficial by Dr. Robert Hamilton ; and it has 
since his time received the warm sanction of many of the most emi- 
nent practitioners. " I know from pretty ample experience," says 
Dr. Johnson, " that in conjunction with antimonial powder, opium 
forms a most admirable auxiliary to mercury in acute hepatitis ; not 
only soothing many uneasy sensations of the patient, but determining 
to the surface and promoting a diaphoresis, which is of infinite service 
in this, as in most other affections."* Dr. Armstrong also expresses 
his confidence in the usefulness of this narcotic in hepatitis ; and, in 
my own practice, I have had unequivocal evidence of its beneficial 
effects in this malady. From three to four grains of calomel, with a 
grain of opium, may be given every four or five hours, and continued 
until the gums are obviously aifected. The addition of two or three 
grains of the pulois cintimonialls, to each dose of the calomel and 
opiimi, will do good not only by its diaphoretic powers, but also, as 

* The Influence of Tropical Climates, &c., vol. i. 



268 ACUTE HEPATITIS. 

it would seem, by its tendency to favour the induction of the mercu- 
rial infiuence ; and our main object must be to bruig the system 
under this influence as early as possible. 

Whilst these articles are given, it will generally be necessary to 
exhibit an occasional dose of castor oil, or one of the sahne purga- 
tives. In the more violent and rapid cases of this disease in hot cli- 
mates, it is often very difficult to obtain the timely operation of mer- 
cury on the system, merely from its internal exhibition. Where there 
is reason to apprehend difficulty in this respect, mercurial frictions 
should be used in addition to the internal employment of calomel. 
One or two drachms of the ung. hydrarg. may be rubbed in on the 
arms or thighs three or four times daily, where pfyalism appears to 
be tardy in its appearance. Dr. Johnson states, « that the absorption 
of mercury into the system, and the consequent early induction of 
general mercurial action, are accelerated by causing the patient to 
swallow a considerable quantity of warm diluting drink, as thin water 
gruel, every night at bedtime." 

The application of blisters large enough to extend over the whole 
right hypochondriac and epigastric regions, is a highly useful measure^ 
after bleeding has been efficiently practised. They almost always 
give considerable relief to the local pain, and by creating a perma- 
nent determination to the external surface immediately over the 
inflamed liver, they tend in no small degree to subdue the local aflcc- 
tion. 

As auxiliaries to bleeding, purgatives, and calomel, antimoniah 
will, in general, be useful where the stomach is not too irritable. The 
pti/vis antimonialis, in doses of about three grains, may be given 
either in combination with calomel and opium, or in union with nitre, 
or the sulphate of potash, every three or four hours ; and to promote 
the diaphoretic operation of these remedies, as well as the specific 
efiects of the mercury, the warm or tepid bath will frequently be found 
Very useful. 

When the inflammation has terminated in siTppuration, (an event 
which is announced by the occurrence of rigors, a sense of sinking 
and anxiety in the praecordia, night sweats, and occasionally formi- 
cation of the skin, with a fullness and feeling of weight about the 
margin of the ribs, and a dull throbbing pain in the liver,) the further 
employment of mercury, with a view to its general influence, is im- 
proper. " If the local symptoms and the state of the pulse and of the 
system seem to require it, the application of a few leeches in the vi- 
cinity of the tumefaction will be generally serviceable ; and afterwards 
poultices should be assiduously employed, with a view of promoting 
the external pointing of the abscess." — (Annesley.) The bowels also 
should be regularly, though gently evacuated, after the formation of 
abscess has taken place, which may be best done by five or six grains 
of calomel, followed in a few hours by a small portion of one of the 
neutral purgative salts. When the abscess does not point externally, 
nothing more can be done than "to palliate symptoms as they rise, 
and wait for the event." In instances where the abscess does point 
outwardly, and the fluctuation of the matter can be distinctly fell, an 



CHRONIC HEPATITIS, 269 

opening should be made into it, and exit given to its contents. "But 
ttiis operation ought not, liowever, to be undertaken precipitately, and 
beibre the purulent formation has made its way sutficiently near to 
the external surface of the organ, or beibre the part at wliicli it points 
has formed adhesions to the opposite part of the abdominal parietes. 
The |)ractitioner should also be fully convinced, from the state of the 
tumour in the liepatic region, and from the history of the case, that 
abscess actually exists, and that the tumour does not proceed from an 
excessive accumulation of bile in the gall-bladder. When the pain 
and general fullness are diminished, and replaced by a distinct tu- 
mour, without acute pain, soft and fluctuating at its apex, or with a 
soft elasticity and slight lividity or redness of the surface, and a some- 
what hardened and elevated base, the operation may be undertakea 
with every expectation of success." 

The operation of paracentesis thoracis has been successfully per- 
formed in cases where the abscess had burst into the cavity of the 
thorax. An interesting case of this kind is related by Mr. Huggins, 
in the London Med. Repos. for July, 1827. 

After suppuration has taken place, and the matter found a favour- 
able exit, there is, perhaps, no remedy which will afford so much 
advantage as the nitro-muriatic acid. It may be employed both inter- 
nally and externally as a foot-bath, in the manner recommended by 
Dr. Scott. Equal parts of the nitric and imiriatic acids are the propor- 
tion in which they are usually employed. From a half to a whole 
drachm of this mixture, diluted in a sufficient quantity of water, may 
be taken daily ; and in order to prevent the acid from coming in con- 
tact with and injuring the teeth, it should he sucked through a 
small glass tube, or a quill : or the feet and legs may be immersed 
from thirty to forty minutes every evening in a warm bath, of the 
strength, at first, of half an ounce of the acid mixture to a gallon of 
water, and afterwards gradually increased in strength to the amount 
of six or eight drachms to the gallon. In two instances of hepatic 
suppuration from acute inflammation, the patients recovered com- 
pletely under the protracted use of this bath. Considerable advan- 
tage may also be obtained, in suppuration of the liver, from small 
doses of the muriate of mercury in union with the extract of cicuta, 
in the proportion of one-tenth of a grain of the former, to two grains 
of the laUer, three times daily. Mr. Annesley has derived advantage 
from the nitric acid in combination with laudanum, hyoscyamus, or 
conium, particularly when the abscess has opened into the lungs. 
When in cases of this kind, the system becomes muchexhausied, and 
the night-sweats are copious, or where the digestive powers fail, re- 
course ought to be had to some of the tonic bitters, in conjunction with 
nitric acid, and the extract of conium. 



Sect. XL — Chronic Hepatitis. 

Chronic inflammation of the liver, when not the consequence of 
an acute attack, of the disease, begins, generally, with symptoms of 



270 CHRONIC HEPATITIS. 

functional disorder of the digestive and biliary organs ; and dyspepsia 
frequently seems to be the only affection present. The patient com- 
plains of irregular appetite, and impaired powers of digestion ; acidity; 
flatulence ; slight colic pains; occasional nausea and vomiting ; and a 
sense of fullness in the region of the stomach. In many instances, a 
slight dull pain and weight are felt in the right hypochondrium, accom- 
panied, in some cases, with a dragging pain in the right shoulder. 
Most commonly, however, no distinct pain is experienced in the 
region of the liver, except when firm pressure is made on this part. 
In such instances, a sense of uneasiness and tightness is usually felt 
in the right hypochondrium; and if examination be made, a manifest 
tumefaction is often discovered in this part. The white of the eyes, 
and skin of the face, neck and breast, become tinged with a yellowish 
hue, and the countenance acquires a contracted and sickly aspect. 
The bowels are always very irregular, costiveness being most com- 
mon, alternating in some instances with diarrhoea, the discharges 
being frequent, scanty, dark-coloured, offensive, slimy, greenish, or 
watery and muddy. The urine is generally highly tinged with bilious 
matter, and creates a sense of scalding in the neck of the bladder on 
being voided.* The tongue is for the most part white, and rather 
dry ; the taste bitter or disagreeable ; and in the advanced periods of 
the disease, the gums often have a peculiar and unnatural firmness. 
One of the most constant and characteristic symptoms of chronic 
hepatitis, is a dry, harsh, and consiricfed state of the skin. (John- 
son.) So torpid are the cutaneous exhalents in this affection, that 
every effort to produce a general moisture, or even softness of the 
skin, is generally abortive. A short dry cough, with slight difficulty 
in breathing, is a frequent attendant on this disease. In the chronic, 
as in the acute form of this disease, the patient can seldom rest as 
easy on the left as on the right side. As the disease advances, ema- 
ciation becomes more and more conspicuous ; slight febrile exacerba- 
tions come on towards evening, attended with a burning heat in the 
palms of the hands and soles of the feet ; the nights are restless ; and 
when the inflammation terminates in suppuration, hectic and rapid 
emaciation consume the vital powers. 

When the convex surface of the liver is the principal seat of the 
inflammation, the pain will be referred to the thorax; but when the 
concave surface is the part chiefly affected, the patient generally refers 
the pain to the stomach or bowels. 

Chronic inflammation of the liver often occurs as a consequence of 
the acute variety of the disease; but it more frequently arises from 
the slow operation of the same causes which excite acute hepatitis. 
From the great frequency of chronic affections of the liver in warm 
and miasmatic situations, there can exist but little doubt, that the slow 
and continued operation of marsh miasmata is a principal cause of 
this affection. That this miasm has a particular tendency to produce 
biliary derangement, seems evident from the sallow and jaundiced 

* Mr. Rose and Dr. Henry assert, that urea and lithic acid are not found in the 
urine of persons labouring under hepatitis. 



CHRONIC HEPATITIS. 271 

appearance of those who reside in marshy districts. The liver being 
in a state of ahnost constant excitation in situations of this kind, and 
finally disordered in its functions, is especially predisposed to conges- 
tion and slow intiammation, on the supervention of any other cause 
capable of deranging the cutaneous or digestive functions. 

Post-morleni aj)pearances. — Chronic inflammation may terminate 
variously. No recent traces of inflammation are detected in the liver 
on post-mortem examination. The viscus usually exhibits an ash 
or clay colour, and is generally somewhat changed from its healthy, 
or natural shape. Dr. Saunders observes, that the lower margin of 
the left lobe, which in the healthy liver is thin, is commonly found 
rounded and gibbous in chronic hepatitis. In some instances the liver 
is of a much more firm and solid consistence than natural, although 
its weight is often specifically lighter than the healthy organ. In 
some cases, particularly in hot climates, the liver suff'ers much greater 
organic destruction than mere change of consistence and colour. Dr. 
Lind found the liver, in persons who had died of this disease, so eaten 
through as to resemble a honeycomb. Suppuration is a common 
termination of chronic hepatic inflammation in India. " Not unfre- 
quently, very minute abscesses are scattered through tiie substance 
of the liver, both with and without the appearance of a distinct cyst, 
the matter collected being of a firm or cheesy consistence, and yellow- 
ish-white colour. (Annesley.) Sometimes, however, one large ab- 
scess is found in the structure of the liver. Tubercles of various sizes 
and appearances, are occasionally found imbedded on the surface, 
and interspersed through the substance of tiie liver. These morbid 
depositions vary in consistence "from a gristly or cartilaginous state, 
to one of semi-fluidity;" the firmer ones when divided often present- 
ing either a concentric or radiated texture. In the most chronic cases, 
the substance of the liver sometimes acquires almost a cartilaginous 
consistence. Annesley states, that in those who had been addicted to 
the use of spirituous liquors, the substance of the liver, besides small 
tubercles, exhibited "a cheesy consistence and texture of a deep nan- 
keen-like colour." Occasionally the liver is firm, and much dimi- 
nished in size, and its internal structure has sometimes exhibited a 
par-boiled, scabrous, dry and spongy appearance.* 

Treatment. — General depletion is very rarely indicated in this 
variety of hepatic inflammation. In cases of a subacute character, 
more especially when they occur as a consequence of an acute attack 
of the disease, it will sometimes be useful to abstract small portions 
of blood ; but even in instances of this kind it will be better to de- 
plete by leeches applied to the epigastrium. " In the chronic hepa- 
titis of India," says Annesley, " there are few cases where repeated 
though moderate leeching will not be advantageous." After each 
leeching, an emollient poultice should be applied over the right hypo- 
chondrium, and a mercurial aperient administered at night. When 
the phlogistic action of the liver has been reduced, (where such 

* Researches into the Causes and Treatment of the Diseases of Warm Climates 
By James Annesley, Esq., p. 470. 



273 CHRONIC HEPATITIS. 

redaction may be indicated by the local pain, and action of the heart 
and arteries,) by moderate depletory and aperient measures, recourse 
should be had to a more regular administration of mercurial reme- 
dies. In the employment of mercury in this affection, however, it 
must be managed so as not to produce active ptyalism. Full saliva- 
tion seldom proves benelicial, and may do injury in this form of the 
disease. A moderate, uniform and prolonged mercurial influence 
will generally procure all the advantage that this remedy is capable 
of affording. From three to four grains of blue pill, in combination 
with a gram of the extract of conium, or of hyoscyamus, should be 
given three times daily, until the gums become slightly affected.* 
The medicine is then to be discontinued until the soreness of the 
gums is going off, when it is to be resumed, and given once or twice 
daily, so as to keep up a uniform impression on the system without 
producing ptyalism. During this mercurial course, mild laxatives 
should from time to time be given, so as to keep up a regular action 
of the bowels. For this purpose, small doses of Glauber's or Ep- 
som salts, or of powdered rhubarb, may be given every second or 
third day, according to the stale of the bowels. Mr. Annesley re- 
commends the following aperient pill in this affection : 

JJ. — Hydr. submuriatis Qi. 

Extract, colocynth. comp. ^ij. 
Aniim. tart. gr. i. 
Pulv. ipecac, gr. iv. 
Sapon. castil. gr. x. 

01. carui q. s. — M. ft. pilul. xviij. S. Two of these pills may be taken 
every night on going to bed. In most cases one pill will be sufficient. 

To preserve the tone of the stomach, as well as the regular action 
of the bowels, it will be useful to prescribe a weak infusion of some 
of the tonic bitters — as gentian, colomba and quassia. A tablespoon- 
ful of an infusion of this kind, with ten or twelve drops of nilric 
acid, may be taken morning, noon and evening. 

Dr. Johnson recommends the following formula as an excellent 
tonic in this affection : 

• R. — Decoct, taraxac. ^iv. 

Carbonat. sodae 3i. 

Extract, taraxac. ^ij. 

Tinct. gentian ^ij; — Misce. S. Take two or three tablespoonfuls twice 
daily. 

« The more the taraxacum is employed," he says, " the more cer- 

* I have been in the habit of uniting small portions of ipecacuanha to the blue 
pill and conium, in this and other chronic complaints. Thus : 
R. — Massas hydrarg. ^i. 

Extract, conii maculat. ^ss. 

Pulv. ipecac. 9 i.—M. Divide into 30 pills. S. Take two every morning, 
noon and evening. 



CHRONIC HEPATITIS. 273 

tain proofs will it afford of its utility." The aperient and diuretic 
qualities of this root are unquestionable.* 

In speaking only of a moderate mercurial action, I refer particu- 
larly to this affection as it is usually met with in the temperate lati- 
tudes. In the intertropical regions, chronic hepatitis is generally 
much more rapid in its progress, and is much more apt to terminate 
in abscess than in the colder climates. In consequence of this it is 
often necessary to employ the mercury more freely, and to carry it 
to the extent of producing salivation. Chisholm and Johnson re- 
commend the production of moderate ptyalism, and there can be no 
question of the general propriety of this practice in hot climates. 

The nitro-muriatic acid bath was some years ago strongly recom- 
mended to the profession, as a remedy in this variety of hepatitis, by 
Dr. Scott, and it has since received the approbation of many other 
practitioners, whose opportunities for testing its virtues in this way 
were very ample. " As a general rule," says Dr. Scott, " it may be 
observed, that whenever the mercurial preparations are indicated, the 
nitro-muriatic acid will be found useful— with this difference, that in 
cases vvliere mercury is highly injurious, from delicacy or peculiarity 
of constitution, or from other causes, the nitro-muriatic acid may be 
employed with safety and advantage." Dr. Johnson, who speaks 
very favourably of tliis remedy in chronic hepatitis, gives the follow- 
ing directions for using it. " Into a glass vessel capable of holding 
a pint or more of fluid, put eight ounces of water : and then pour in 
four ounces of nitric, and the same quantity of muriatic acid. One 
ounce of this mixture to a gallon of water will form a bath of a 
medium strength. The feet and legs of the patient are to be im- 
mersed in this bath at the temperature of about 96°, and kept there 
twenty minutes, or half an hour, just before going to bed. This 
should be done every night, and the same bath will remain good for 
five or six nights." If no prickling or itching sensation is felt in the 
feet and legs after they have been immersed for twenty or thirty 
minutes, more of the acid must be added to the bath. The nitro- 
muriatic solution may also be used with benefit in the form of a wash. 
Two or three drachms of the above mixture should be added to a 
pint of warm water, and the body and thighs sponged with it, night 
and morning, for fifteen or twenty minutes at a time. Mr. Annesley 
states, that " he found great advantage from employing this solution 
in the form of a poultice in torpor of the liver, and in chronic affec- 
tions of the organ attended with enlargement, and a deficient and 
morbid state of the biliary secretion." Mr. Annesley speaks in the 
most favourable terms of this remedy in chronic affections of the 
liver. Where the structure of this organ is enlarged, and the biliary 
and intestinal secretions disordered, he declares this mixed acid 
"one of the most valuable remedies we possess." I have frequently 
used it in affections of this kind, and generally with marked advan- 
tage. 

The internal use of the nitrons acid also has been found very 

* Med. Chir. Rev., Jan., 1829. 
VOL. I. — 18 



274 , SPLENITIS. 

beneficial in this affection. From two to four draclims diluted in a 
large portion of some mucilaginous fluid, may be taken in the course 
of twenty-four hours. It seldom fails to induce more or less ptyalism, 
when its employment is continued for some time; but it often acts 
beneficially without the production of sahvation. It may be given 
simultaneously with mercury. (Annesley.) Sir James M'Grigor, 
indeed, thinks that peculiar advantages result from the conjoined use 
of these remedies. 

Blisters are beneficial in chronic hepatitis ; but I have generally 
seen more advantage derived from pustulation of the right hypo- 
chondrinm by frictions with tartar emetic ointment. The white pre- 
cipitate ointment forms a most excellent counter-irritating applica- 
tion in this affection. Two drachms of white precipitate, rubbed 
up with an ounce of lard, and applied two or three times daily by 
frictions to the region of the Uver, will seldom fail to bring out a 
copious crop of large suppurating pustules, more permanent than 
those which are produced by tartar emetic, and much less painful 
and irritating. A seton in the right hypochondrium has been found 
very useful in the more chronic instances of this affection. 

The diet should be light, unirritating and digestible; and the 
patient must especially avoid a cold and damp atmosphere ; or the 
influence of sudden changes of atmospheric temperature. In gene- 
ral, persons who are afiected with this disease are peculiarly sensi- 
tive to low temperature ; and it is a matter of considerable conse- 
quence to the successful issue of our remedial efforts, to place such 
patients in a temperature perfectly agreeable to their sensations and 
uniform in its grade. 



Sect. XII.— 0/ Splenitis. 

The physiological relations of the spleen are as yet but very im- 
perfectly understood ; nor have the diseases to which it is subject 
been « either carefully studied or clearly revealed." '< Our ignorance 
of its use during health has rendered us less alive to its conditions in 
disease ; and the obscurity of its functions when natural, has made 
their study when disordered less, interesting in its object, and less 
successful in its issue." It does not appear that this viscus is often 
the seat of active or acute inflammation,* although chronic inflam- 
mation is probably much more common than is generally suspected.t 
When acutely inflamed, the patient commonly feels a heavy pain 
under the false ribs of the left side, which is considerably increased 

* [I have never seen more than one case of acute splenitis; and that was a 
decisive one. The tenderness of the tumefied organ was peculiar and excessive, 
and the constitutional disturbance was very severe. For three days the symp- 
toms were alarming; but active depletion, general and topical, foUowed by active 
mercurial cathartics, finally gave relief. Mc.l 

t Richter thinks that chronic splenUis is even more common than chronic hepa- 
iti8.— Die Spxielb Therapie, band. i. s. 576. 



SPLENITIS. 275 

by external pressure. The left hypochondrium is said to become 
fuller than natural, and in some instances, considerable pain is felt 
under the riglit scapula. The skin and eyes become slightly jaun- 
diced, and the urine highly tinged with bilious matter. A burning 
and oppressive sensation in the stomach, with nausea and vertigo, 
particularly when the patient raises himself in bed, and other dys- 
peptic symptoms, frequently attend the affection.* 

In chronic splenitis, slight uneasy and occasionally painful sensa- 
tions are from time to time experienced by the patient; and there is 
difficulty in lying on the left side, accompanied with dyspeptic symp- 
toms, a cachectic aspect of the countenance, and a gloomy, morose, 
desponding, or variable and fretful temper. Persons affected with 
chronic inflammation of the spleen are said to be prone to attacks of 
vomiting of blood — (iMarcus, Richter,) — more especially when the 
inflammation has terminated in induration of this viscus. The blood, 
perhaps, passes into the stomach through the vasa brevia. 

From the foregoing symptoms, it is manifest that tfie diagnosis 
between this affection and hepatitis must always be attended with 
considerable uncertainty. The pain in the left side, and the vertigo 
when the head is raised, or on sitting up, are the only symptoms 
mentioned that are not as common in the latter as in the former 
affection. 

Inflammation of the spleen may terminate in suppuration, soften- 
ing of its structure, {rmnollissement,) hypertrophy and induration. 

Suppuration, however, occurs but very rarely in this affection. 
M. Jaquinelle relates an instance in which a large abscess in the 
spleen had burst into the colon; and Wardrop found nearly the 
whole structure of this viscus converted into an abscess containing 
a purulent fluid. Dr. Tweedie, physician to the London Fever Hos- 
pital, has related a case of inflammation of the spleen which termi- 
nated in suppuration; and Dr. Raikem, of Volterra, has given an 
account of a similar case. In Dr. Tweedie^s case two abscesses 
were formed in the spleen, one in the centre, and another at the 
point of its adhesion to the diaphragm, the peritoneal covering and 
fibres of which it had destroyed. In Dr. Raikem's case, the interior 
of the spleen was hollowed out into one great abscess..'"t 

Softening of the structure of this organ is a very common occur- 
rence, particularly "after some forms of general disease." In fatal 
cases of lyphus, rnrnollissement of the spleen is almost always pre- 
sent. J Ttiis softening consists of "a broken down semi-fluid pulp, 
resembling black currant jelly." (Abercrombie.) 

Enlargement of the spleen is particularly apt to occur in remit- 
tents and intermittents. It is probable, however, that this condition 
is rarely the consequence of inflafnm a lion— being the result, gene- 

* Marcus, vide Annalen der Medizin, band. vii. s. 327. 

t Edin. Med. and Surg. Jour., April, 1830. 

t Dr. Vetch, physician to the Charter-house, mentions the following symptoms 
as generally accompanying enlargement of the spleen. There is little or no pain 
complained of by the patient; "the appetite is usually good, yet the powers of 



276 SPLENITIS. 

rally, of great and protracted sanguineous congestion of this organ. 
During the cold stage of intermittents, the spleen always becomes 
greatly engorged with blood, and when this disease continues a long 
time, enlargement, induration, and sometimes a complete disorgani- 
zation of this organ take place. Dr. Vetch states, that in the only 
three cases of intermitting fever which he has known to terminate 
fatally during the cold stage, the spleen was found so much distended 
with blood, and its structure so much altered, that it resembled a 
mass of dark uncoagulated blood, which was broken down by slight 
pressure of the finger. This state of the spleen is attended with 
great increase of its vascularity, whilst little or no morbid change 
usually occurs in its proper substance. Dr. Abercrombie observes, 
that " one of the most singular facts in the pathology of the spleen, is 
the very rapid manner in which enlargement of it takes place; and 
the equally rapid manner in which it subsides."* 

In some instances, tubercles and hydatids are found in the spleen ; 
and authors mention a pale induration of this organ as an occasional 
phenomenon. (Diemerbroeck.) Dr. Abercrombie mentions, also, 
infiltration of a gelatinous fluid, and deposition of adipose matter 
into the substance of the spleen. 

Treatment. — Acute inflammation of the spleen is to be encoun- 
tered with the usual antiphlogistic remedies proper in visceral inflam- 
mations. Decisive blood-letting, purgatives, and counter-irritating 
applications to the region of the spleen, constitute the principal means 
for combating this affection. The warm bath, after the active state 
of the disease has been in some degree reduced, is said to be a useful 
auxiliary. 

In the chronic form of the disease, leeching and pustulation of the 
left hypochondrium by frictions with tartar emetic ointment; the 
warm bath; mercurial laxatives; a seton in the left side; alterative 
doses of blue pill with extract of hyoscyamus; diaphoretics; and 
the protracted use of minute doses of tartar emetic, are the remedies 
upon which our chief dependence is to be placed. 

assimilation are obviously deficient ; the patient loses flesh ;t is incapable of any 
muscular exertion ; his features have a dark, bilious, or mahogany hue, but the 
conjunctiva preserves a vs^hite and healthy appearance ; perspiration is in time 
wholly suspended, and the skin acquires the appearance and feel of satin ; the 
lips are pale, and there is generally much wasting of the gums; the urine is 
limpid, and secreted very rapidly, but contains little or no urea. The patient's 
mind is desponding and morose ; and there is coldness of the lower extremities." 
— Med. and Phys. Journal, 1824. 
* Med. Chir. Rev., January, 1829. 



t [Infants are sometimes affected with permanently enlarged and very indurated 
spleens, which produce extreme anemia without any remarkable degree of ema- 
ciation. Dr. Elliotson thinks such cases proceed from the parents having been 
exposed to marsh miasma. I have seen them where no such cause could be 
suspected. Chalybeates and iodine are the only remedies; but my success has 
been poor enough with them. — Mc] 



INFLAMMATION OF THE BRAIN. 277 

In« enlargement and induration of the spleen, particularly when they 
occur as the sequelae of intermitting fever, I have found no remedy 
more useful than large doses of the muriate of ammonia. The for- 
mula given in the chapter on intermitting fever may be employed 
with a pretty certain prospect of success in cases of this kind. Small 
doses of tartar emetic, also, are decidedly beneficial in enlargement 
of the spleen. One grain dissolved in two quarts of some bland fluid 
or water, may be taken in place of the common drink, and continued 
for eight or ten days. Alterative doses of blue pill with ipecacuanha, 
in the proportion of two grains of the former to one of the latter, will 
frequently succeed in removing this state of the spleen. The bowels 
must be regularly moved by some mild aperient ; and the diet should 
be mild, digestible, and nourishing. The warm bath, and frictions 
with dry flannel or the flesh brush, will assist in the removal of this 
affection. 

Iodine has recently been employed for the reduction of enlarge- 
ment and induration of the spleen ; and it would appear to possess 
very active powers against this affection. It may be used either 
internally in the form of tincture ; in doses of from eight to ten drops 
three times daily; or in frictions with the hydriodate ointment, over 
the region of the spleen.* 



CHAPTER XL 

OF THE PHLEGMASIiE OF THE NERVOUS SYSTEM. 

The pathology of encephalic inflammation is attended with much 
difficulty on account of the variety of structures which compose the 
encephalon, and the consequent diversity which occurs in the symp- 
toms and terminations of its inflammatory affections. Within the 
cranium there are no less than three distinct structures, namely, the 
fibrous, the serous, and the cerebral, and there is reason to presume, 
that the phenomena of cephalitis will be considerably modified, ac- 
cording as one or the other of these structures is the principal seat of 
the inflammation. It is not probable, however, that any one of the 
structures within the cranium can suffer inflammation, without in- 
volving, in some degree, the others ; and all attempts, therefore, to 
assign to each structure its peculiar symptoms under inflammation, 
must necessarily be attended with considerable uncertainty. Never- 
theless, there are certain modifications of the phenomena of cepha- 
litis, which observation has taught us to refer to particular structures, 
and which may, therefore, be taken as a basis for the division of 

* [The most decisive effects in enlargement of the spleen have been produced 
in my hands by occasional doses of Clutterbuck's extract of elaterium, in combi- 
nation with a small proportion of calomel. — Mc] 



278 INFLAMMATION OF THE BRAIN. 

encephalic inflammation into certain varieties, sufficiently distmct to 
demand separate consideration. 

Agreeably to these circumstances, cephahtis presents us with the 
following varieties, viz. : 

Meningitis and cere6ri7w.— Meningitis must be again divided 
into inflammation of the pia mater, with more or less inflammatory 
action in the rest of the membranes and the brain ; and arachnitis. 
The first of these subdivisions constitutes the aflTection comrnonljr 
called phrensy (phrenitis ;) and the last is known under the inappro- 
priate name of hydrocephalus. 



Sect. I. — Phrenitis [Phrensy). 

Phrenitis generally begins with pain and a sense of fullness in the 
head, attended, in most instances, from the commencement, with 
considerable nausea and vomiting. As the pain and febrile reaction 
increase, the eyes become red and sparkling ; the face flushed ; and 
the patient often experiences a peculiar sensation of uneasiness along 
the course of the spine. Delirium is commonly an early attendant 
on the disease, and in most instances, soon acquires a degree of vio- 
lence resembling the most furious and ungovernable mania. In this 
aggravated state of the disease, the face becomes turgid ; the eyes 
wild and furious ; the carotids beat strongly ; vision is impel feet and 
deceptive ; and the whole system is in a continued state of restless- 
ness or agitation. During the early part of the disease, the sense of 
hearing is generally painfully acute, but in its advanced periods, 
complete deafness often occurs. At first, the pulse, along with its 
firmness and activity, has considerable volume'; but in the progress 
it becomes small and tense, and not unfrequently intermitting. 
Respiration, though hurried and anxious at first, becomes slow, 
deep, and somewhat laborious in the latter stage of violent instances 
of the disease; and in many cases deglutition is performed with 
much difficulty. 

The liver often sympathizes strongly with the brain in this disease, 
giving rise to a copious secretion of bile,' jaundice, and other mani- 
festations of hepatic derangement. Dr. Wilson observes, " that there 
is often a remarkable tendency to the worst species of haemorrhages 
from the bowels, towards the termination of fatal cases ;" an ob- 
servation which was confirmed by a remarkable instance which came 
under my own notice. On the day preceding the fatal termination 
of this case, an exceedingly copious discharge of dissolved blood took 
place from the bowels, and on the following morning the haemorrhage 
occurred also from the mouth and gums. 

Causes. — Phrenitis is not often an idiopathic affection. It occurs 
most commonly during the progress of general fevers, particularly 
synocha, and the aggravated instances of typhus. The ordinary ex- 
citing causes of this variety of encephalic inflammation are, violent 
passions ; insolation ; the sudden influence of cold while the body is 
ill a state of free perspiration j drunkenness j suppression of habitual 



INFLAMMATION OF THE BRAIN. 279 

sanguineous discharges ; and particularly metastasis of gout, erysipe- 
las, and parotitis, and the extension of other external inflammations 
about the head to the brain, an occurrence sometimes met with in 
small-pox. I have known the disease to supervene in consequence 
of a large phlegmonous sweUing under the left ear ; and another in- 
stance, from a similar itiflammation on the back of the neck. 

Prognosis. — Haemorrhages, in the advanced period of the disease, 
particularly from the bowels, may be regarded as almost a certainly 
fatal sign. Bleeding from the nose, however, at an early period, 
seldom fails to mitigate the violence of the disease, and should always 
be promoted as a most favourable occurrence. Coma supervening 
on violent delirium, is indicative of great danger; for after the occur- 
rence of this symptom, little or no hopes of recovery can be enter- 
tained. 

Phrenitis is always attended with considerable danger ; and the 
unfavourableness of the prognosis must of course be proportionate to 
the violence of the symptoms, and the obstinacy with which they 
resist remedial treatment. Morgagni observes, that when plirenitis 
supervenes on peripneumony, the worst consequences are to be ap- 
prehended; and the same observation is made by Schmidtmann.* 

Pathology. — It is stated above, that in the disease just described, 
the inflammation is principally located in the pia and dura mater; 
and this appears to be entirely confirmed by the phenomena which 
are presented on post mortem examination. I am aware, that Bi- 
chat asserts that the dura mater is scarcely susceptible of inflamma- 
tion ;t but this assertion is contradicted by others, and with justice. 
Shaw, in his Manual of Anatomy, states, that after phrenitis, the 
traces of inflammation are always very conspicuous on the surface of 
the dura mater, "which is generally as much blood-sliot as the con- 
junctiva in ophthalmia, with layers of lymph occasionally on the 
inner surface." The observations of Morgagni, also, go to establish 
the same fact ; for, in nearly all the dissections which he relates of 
subjects who had died of this disease, the pia and dura mater 
showed the strongest signs of previous inflammation. The substance 
of the brain itself does not often exhibit unequivocal traces of inflam- 
mation in those who die of phrenitis ; but in nearly all instances, 
flakes of coagulable lymph, and often pus mixed with serum, are 
found between the membranes, and in some cases the dura mater 
has been found eroded to a considerable extent. (Morgagni.) In- 
deed, inflammation of the cerebral substance alone is very rarely 
attended with the violent delirium and pain which distinguish the 
affection under consideration ; nor is delirium a very constant and 
prominent phenomenon of arachnoid inflanmiation, though fre- 
quently connected with very severe and lancinating pains in the 
head. It cannot, indeed, be doubted, that the brain becomes more 
or less involved in the inflammation which constitutes this disease, 
but the principal seat of the inflammation would seem to be placed 

* Summa Observationem Medicarum, vol. i. Berlin, 1819. 
t Pathological Anatomy, translated by I. Togno, M. D., p. 58. 



280 INFLAMxMATION OF THE BRAIN. 

in the pia and dura mater. Morgagni states, that he has found the 
membranes alone affected, although, in the majority of cases, traces 
of inflammation were also discovered in the cerebral structure. 

Treatment.— There is no inflammatory aflfection which more 
urgently demands a vi2;orous antiphlogistic treatment than the pre- 
sent one. Blood-letting, promptly and efficiently used, is a sme qua 
non in the remedial management of this afl"ection, as indeed it is in 
all the modifications of cephalitis. Many of the other phlegmasia! 
diseases may often be treated successfully without sanguineous deple- 
tion. Pneumonia is treated by some* with opium and calomel; and 
by others.! with tartar emetic, with little or no abstraction of blood. 
But phrenitis is, perhaps, never treated with success without efficient 
blood-letting, nor is it likely that any other remedial measures would 
be of adequate avail, without the aid of this most prompt and effi- 
cient of all our antiphlogistic means. Blood should be draAvn from 
a large orifice, and suffered to flow until unequivocal signs of its 
effect on the action of the heart and arteries are manifested. Carried 
to the extent of inducing an approach to syncope, bleeding will gene- 
rally speedily subdue the furious delirium and intense pain in the 
head. In all inflammatory affections of the head, particular advan- 
tage may perhaps be obtained by taking the blood from one of the 
jugulars or the temporal arteries. Although bleeding is always most 
serviceable when adequately performed in the onset of inflammatory 
affections, yet in the present disease it may be advantageously resorted 
to throughout the whole course of the malady, if the pulse remains 
tense and quick. J Topical bleeding by leeches or cups, is less bene- 
ficial in this than in the less violent forms of encephalic inflammation 
in its early stage. § After the momentum of the circulation has been 
diminished by general bleeding, leeches or cups, applied to the tem- 
ples and about the head, will in general procure considerable advan- 
tage. The application of cold water or ice to the head is a valuable 
auxiliary in the treatment of this disease. The hair should be cut 

* Schmidtmann, Vogel. 

t Rasori; and the advocates of the contra-stimulant doctrine. 

% [After the first blood-letting the pulse should be carefully watched, and at 
every subsequent reaction the bandage should be removed, and more blood 
drawn from the same orifice. I have in this way repeated the evacuation several 
times on the first day with the most decisive effect. — Mc] 

^ Mr. ChaufTard states that he has often seen an inflammatory affection of the 
head aggravated by leeches to the temples or behind the ears, and relieved at 
once by drawing blood from the feet and ankles. He mentions several cases of 
ophthalmia, unchecked and uncured by local bleedings from the neighbourhood of 
the eyes, speedily disappear by the application of leeches to the lower extremi- 
ties. The good effects are much enhanced by the warm hip or foot baths; cold 
applications at the same time kept constantly applied to the head. — Med. Chir. 
Rev., 1832, p. 188. 

Dr. Johnson observes that '-revulsive bleeding" may be used with exceeding 
good effects, especially in those cases of cerebral disease dependent on obstruc- 
tion of any accustomed discharge. 



INFLAMMATION OF THE BRAIN. 281 

short, or shaved off, and bladders partly filled with cold water, into 
which a lump of ice is put, should be kept constantly applied to the 
top of the head. Purgatives of the active kind will assist materially 
in reducing encephalic inflammation. 

In all affections of the head, whether congestive or inflammatory, 
there is usually considerable torpor of the intestinal canal, and it is 
generally necessary to prescribe large doses of some active purga- 
tive to procure an adequate evacuation of the bowels. As the liver 
usually sympathizes strongly with the brain in its inflammatory affec- 
tions, calomel forms an appropriate constituent in the purgatives pro- 
per in this disease. From ten to twelve grains of this article, followed 
after the lapse of three or four hours with infusion of senna, or a full dose 
of Epsom or Glauber's salts, will in general answer well as a purga- 
tive in this affection. Care must be taken in the use of calomel, lest 
ptyalism be induced, an occurrence which could hardly fail proving 
injurious. The bowels should not be suffered to remain inactive for 
more than five or six hours at a time, and this should be attended to, 
not only during the active course of the disease, but throughout the 
period of convalescence. Cathartics do good in this affection, both 
as revulsive and evacuant means. By exciting the intestinal exha- 
lents, and thus directing the circulation more particularly to them, 
purgatives tend, in no inconsiderable degree, to diminish the flow of 
blood to the head, as well as the general momentum of the circula- 
tion, by their indirect depletory effects, and the removal of irritating 
matters from the intestinal canal. 

Many writers recommend the application of blisters to the head, 
after the violence of the febrile excitement had been in some degree 
subdued by the depletory measures. In the early periods of the dis- 
ease they are useless, and perhaps injurious, but when the violence 
of the inflammation is moderated, and the disease, as it were, linger- 
ing on the confines of convalescence, advantage may, perhaps, be 
derived from vesicatories applied to the shaven scalp. It has ap- 
peared to me, however, that more benefit is derived in the inflam- 
matory affections of the brain, from blistering the back of the neck, 
than from vesicatories laid on the top of the head. When applied 
on the neck we may at the same time continue the use of cold appli- 
cations to the scalpj a union of applications particularly appropriate 
to this disease. 

The patient's head should be kept in an elevated position, in order 
to lessen the impetus of the circulation in the affected parts. In all 
inflammations, considerable benefit accrues from placing the inflamed 
part, if feasible, in a raised position, as we thereby favour the return 
of the blood from the inflamed structure by the veins, and impede, in 
some degree, the access of the blood by the arteries, in consequence 
of the additional resistance offered by the gravity of the blood to the 
propulsive efforts of the heart. 

Among the internal antiphlogistic means, viire,'m combination with 
antimony, or digitalis, may be accounted the most useful. From 
ten to twelve grains of the' nitrate of potash, with half a grain of 
digitalis, may be given every two hours. Digitalis is particularly well 



282 INFLAMMATION OP THE BRAIN. 

suited to the management of this, as well as of other inflammatory 
afiections, after the violence of the disease has been broken down by 
the remedies already mentioned, and when it continues its course in 
a reduced or subacute form. Given in small and frequent doses, it will, 
under these circumstances, often make a very decided and salutary 
impression upon the action of the heart and arteries. From a quarter 
to half a grain of the powdered leaves may be given every two 
hours, until it either causes a reduction of the frequency and activity 
of the pulse, or produces nausea or other symptoms of gastric dis- 
turbance. 

During the whole course of the disease, the chamber of the patient 
should be kept dark, silent, and cool, and every thing avoided which 
has a tendency to disturb or excite the system. No nourishment 
whatever, with the exception of toast- water and lemonade, or similar 
beverages, must be allowed, so long as there are pain in the head, and 
general febrile irritation. 



Sect. II. — Arachnitis. 

Hydrocephalus acutus; acute dropsy in the brain ; apoplexia hy- 
drocephalica — ( Citllen.) Encephalitis — {Porter.) Phrenicula 
— {Rush.) Hydeiicephalus — {Smith.) Cephalitis profunda — 
{Good.) 

Arachnitis is a much more common form of encephalic inflamma- 
tion than the preceding one.* It has of late years been extensively in- 
vestigated by Martinet and Duchatelet, of Paris, and by Dr. Abercroin- 
bie, of Edinburgh, whose pathological researches in relation to this 
subject are highly interesting and valuable. I treat of hydrocephalus 
and arachnitis under the same head, for it is now placed beyond all 
doubt, that the malady known and described under the name of hy- 
drocephalus, consists essentially of arachnoid inflammation. The 
term hydrocephalus is, indeed, altogether inappropriate to the disease ; 
for, instead of directing the mind to the primary and essential affec- 
tion, it has reference only to one of its ordinary consequences — namely, 
serous effusion on the surface and within the cavities of the brain. 
Dr. Rush was one of the first who taught correct views concerning 
the pathology of this disease. " Having for many years," he says, 
" been unsuccessful in all cases but two of internal dropsy of the 
brain which came under my care, I began to entertain doubts of the 
common theory of this disease, and to suspect that effusion of water 
should be considered only as the effect of a primary inflammation in 
the brain." He regared this disease as a subacute grade of cerebral 

* Dr. Coindet states, that in France, 20,000 deaths occur of this disease annu- 
ally, while Dr. Alison informs us, that 40 out of 120 patients die of this affection 
in the New-Town Dispensary ; and, according to the late Dr. Davis, of London, 
8 out of 45 deaths in the Universal Dispensary were produced by hydrocephalus. 
Med. Chir. Rev., March, 1828, p. 385. 



INFLAMMATION OF THE BRAIN. 283 

inflammation, or an inflammation less violent than that which gives 
rise to the symptoms of phrenitis, and therefore distinguished it by 
the name of phrenicula*- The impropriety of designating this dis- 
ease by the name of dropsy, is often strikingly exemplified by the 
post-mortem phenomena ; for, in some instances, very little or no se- 
rum is eflTused into the ventricles, or upon the surface of the brain, 
although the symptoms were unequivocally those which are acknow- 
ledged to characterize hydrocephalus. — (Abercrombie.)t 

It is, nevertheless, probable that efl'asion within the cavity of the 
cranium does sometimes occur without inflammatory action of the 
vessels of the encephalon, from mere congestion of the cerebral 
blood-v^essels. This is, perhaps, the case in some of the instances 
which are ushered in by convulsions, or a state of somnolency and 
stupor, without any manifest previous febrile irritation. Be this as it 
may, arachnoid inflammation constitutes unequivocally the essential 
pathological condition of what is generally known under the deno- 
mination of hydrocephalus. 

Arachnitis occurs most commonly during childhood ; and the pe- 
riod of dentition is the age during which the greatest aptitude exists 
to the disease. That there should be a particular proneness to this 
malady during the process of dentition is easily to be understood. 
Whilst this process is going on, there is almost always more or less 
local irritation in the immediate vicinity of the brain, connected with 
a general irritable and phlogistic condition of the system — circum- 
stances which, co-operating with the natural predominance of the 
cerebral circulation in infancy, are well calculated to invite to inflam- 
matory affections of the head during this period of life. 

Symptoms. — Arachnitis may be divided into three stages. The 
first stage may be called the irritative period; for, in the commence- 
ment of the disease, the symptoms are those of an irritated, rather 
than an inflamed condition of the brain. The approach of the dis- 
ease is frequently very gradual, more especially during early child- 
hood. In many instances, the brain manifests a very irritable con- 
dition for several weeks previous to the full development of the 
disease. The patient is wakeful ; irritable in temper ; evincing a 
repugnance to strong light, on account of the sensible state of the 
retina; the pupils are contracted ; the disposition fretful and variable ; 
small children cry frequently, without any apparent cause, and, when 
sleeping, often start or awake suddenly, with violent screaming, " and 
an expression of terror in the countenance." Nurslings, when 

* Dr. Porter contends that hydrocephalus is not phrenitis, (though he admits 
that meningitis may be superadded,) but an inflammatory condition of the poste- 
rior arteries of the encephalon, and of the base of the brain. — Med. Chir. Joum., 
July, 1819. 

t [In the majority of all the cases in which I have raadie post-mortem examina- 
tions for acute hydrocephalus in children, I have been disappointed in regard to 
the anticipated efl'usion. Inflammation of the enveloping and penetrating portion 
of the membranes has always predominated, and often the cerebral injection has 
terminated in bloody extravasation. — Mc] 



284 INFLAMMATION OF THE BRAIN. 

awake, often « start at the slightest noise, and shriek suddenly as if 
pricked with a pin."* This state of cerebral irritability sometimes 
exists and continues for a time without passing into the inflammatory 
state ; the child gradually returning to its ordinary condition of health. 
When, in this state, some additional exciting circumstances supervene 
— such as cold, dentition, or intestinal irritation from improper food, 
or other irritating substances lodged in the bowels, this irritative con- 
dition of the brain is increased, and sooner or later converted into 
inflammation. A new train of phenomena now ensues, which cha- 
racterizes the inflammatory, or second stage of the disease. The 
patient complains of transient pains in the head, alternating often 
with similar pains in the abdomen. The restlessness and irritability 
of temper increase; the pulse is irritated, qiiick, tense and active; 
the physiognomy expressive of discontent and suffering ; one or both 
cheeks marked with a circumscribed flush ; the eyebrows knit and 
frowning; and the eyelids generally half closed, on account of the 
sensible state of the retina. The bowels are commonly torpid, and 
sometimes relaxed, the stools presenting an unnatural appearance. 
As the disease goes on, the cephalic pains become more and more 
severe, suffering occasional remissions, and sometimes subsiding en- 
tirely for a few minutes. These pains are felt chiefly in the forehead, 
shooting backwards towards the temples. Children manifest their 
suflferings from the headache, by frequently applying the hands to the 
forehead. At this period of the disease, the stomach is usually very 
irritable — the retching and vomiting becoming often very trouble- 
some, particularly when the patient is raised to a sitting posture. I 
have met with many instances in which no disposition to vomit was 
manifested whilst the patient remained in a recumbent position; but 
the moment the head was raised from the pillow, sickness and vomit- 
ing ensued. Indeed, children affected with this disease always bear 
the erect position with great uneasiness. « In the early part of the 
disease, the little patient cannot sleep with the head low ; he lies in 
the bed with outstretched arms, which have a tremulous motion ; are 
often directed towards the head, and firmly clasped upon it ; he is 
constantly turning and tossing from one side of the bed to the other, 
and very frequently groans much, as if under the influence of pain." 
(Monro.) The sickness of the stomach sometimes alternates with 
the cephalic pains. (Quin, Fothergill.) One of the most common 
and characteristic symptoms of this complaint is frequent and deep 
sighing ; though this is seldom much noticed until the disease is fully 
developed, and is generally most remarkable about the period when 
the inflammation is about terminating in effusion. During the latter 
part of the inflammatory stage, transient delirium usually occurs: 
but the delirium of arachnitis is never violent or furious, but of the 
tranquil kind, and rarely so great that the patient may not be roused 

* Dr. W. NichoU's Transact, of the Association of Fellows and Licentiates of 
the King and Queen's College, Dublin, voL iii. Practical remarks on disordered 
stales of the Cerebral Structures occurring in Infants. By W. NichoU, M.D., 
London, 1821. 



INFLAMMATION OF THE BRAIN. 285 

from it, so as to give distinct answers. (Martinet.) The skin in this 
stage is generally above the natural temperature, and dry ; the tongue, 
for the most part, remains clean, or covered only with a thin white 
fur, with pale red edges. In cases, however, which depend on 
gastric irritation, it is apt to be covered with thick brown fur, becom- 
ing dry and rough towards the termination of the disease. After an 
indefmite period, these inflammatory symptoms are succeeded by a 
new train of phenomena, marking the third stage or the period of 
cerebral oppression. The delirium is now more continuous; the 
countenance exhibits an aspect of surprise and stupor; the pupils 
are dilated or much contracted ; the conjunctiva is suffused and 
reddish; the eyes turned up under the upper lids during sleep ; con- 
stant somnolency supervenes, the patient being wholly inattentive 
to surrounding objects, and when roused, speedily relapses into the 
same somnolent state. The mind is torpid, and apparently inca- 
pable of any attention. The drowsiness increases more and more, 
until a complete state of coma ensues. In some instances, the coma 
comes on suddenly in conjunction with paralysis of one side of one 
extremity ; bnt it more commonly approaches in the gradual manner 
just described. Indeed, instances occur, in which no febrile excite- 
ment is developed, the first manifestations of the disease being an 
unusual drowsiness or torpor. In this latter case, arachnoid inflam- 
mation exists, no doubt, without showing itself by its usual symp- 
toms; for it is well ascertained that inflammation may go on in the 
brain, even to the extent of terminating in extensive and fatal dis- 
organization, without causing either pain or any other general symp- 
toms characteristic of inflammation. Soon after the somnolent stage 
supervenes, paralytic affections generally occur. A tremulous motion 
of one arm, with the hand firmly contracted inwards, is usually one 
of the first manifestations of paralysis in infants ; and, by degrees, 
the power of using the arm and leg of one side becomes entirely 
lost ; one or both upper eyelids usually becoming paralyzed at the 
same time, so that the patient, in endeavouring to look at any thing, 
is unable to raise the lids by their proper muscles, and is, therefore, 
obliged to draw them up with the integuments of the forehead, by 
the contraction of the occipito-frontalis muscle.* Previous to the 
occurrence of paralysis, strabismus almost always occurs, and in 
many instances, there is double vision. In general, a sudden amend- 
ment in nearly all the symptoms takes place soon after the inflamma- 
tion has terminated in eflfusion ; and parents and friends, nay, even 
physicians, may be deceived into the hope that the disease is about 
assuming an unexpected favourable change. This flattering calm is, 
however, seldom of long continuance, and almost universally ulti- 
mately fallacious ; for, sooner or later,convulsions suddenly supervene, 
or the patient relapses into a state of fatal coma and stupor. Con- 
vulsions rarely, if ever, remain wholly absent towards the fatal ter- 
mination of this disease. During the somnolent stage, the pulse is 

* Recherches sur I'Inflammation de I'Arachnoide, Cerebrale et Spinale. Par 
Parent Duchatelet et L. Martinet. Paris, 1821. 



286 INFLAMMATION OP THE BRAIN. 

generally slow and full, and often irregular; but in the convulsive or 
paralytic period, it becomes frequent, small and irregular. In the 
latter stage of the disease, both hearing and seeing are often totally 
lost, yet general sensibility, or the sense of touch, usually remains to 
the last moments. I have seen infants, perfectly deprived of the 
sense of seeing, and apparently of hearing, readily lay hold of the 
nipple and suck as soon as it was brought in contact with the lips, 
although in a continued state of stupor or sleep. The paralysis 
which occurs in the latter stage is always of the hemiplegic kind. 
In most cases, small children keep one arm in continued motion. 
(Cheyne.) Martinet and Duchatelet state, that patients suffering 
under this disease exhale a very disagreeable odour, which they com- 
pare to the smell of mice. 

Arachnitis does not, however, always come on in the gradual man- 
ner and with the regular train of symptoms just described. Some- 
times the disease commences and proceeds in a manner very similar 
to the infantile remittent ; and at others it is ushered in by convul- 
sions, without any perceptible antecedent febrile irritation. In this 
latter case, however, there is, perhaps always some evidence of ill 
health, previous to the supervention of the convulsion, such as fret- 
fulness, variable appetite, irregular state of the bowels, tumid abdo- 
men, foul breath, swelled upper lip, starting, and grinding the teeth, 
during sleep, and other symptoms indicative of intestinal irritation. I 
have known the disease to commence and proceed to the last stage 
with scarcely any other symptom than slight febrile irritation, with 
little or no pain in the head, but a constant and nearlij ineffectual 
desire to pass urine. In one instance there was not above a gill of 
urine discharged in twenty-four hours during the first five days of 
the malady, and no other particular morbid condition was percepti- 
bly present. In this case the urine was not retained, for the intro- 
duction of the catheter brought off' none. Dr. Monro observes, "that 
there are cases in which the little patient has a desire every hour to 
pass water;" and states that he "attended a child affected by this 
disorder, who passed for some days very little urine." The liver 
generally sympathizes strongly with the brain in its inflammatory 
affections. During the former stage of the present complaint there is 
usually a deficiency of bile ; but in its advanced periods, the bile is 
not only more copious, but vitiated in its quality— the stools acquiring 
from its admixture with the ordinary secretions and contents of the 
bowels a dark glairy, or deep green appearance, resembling, as Dr. 
Cheyne observes, " chopped spinag-e.'' 

Z>/«^no5/.?.— The characteristic symptoms of the first stage are: 
irritability of temper ; irregularity of the bowels ; variable appetite; 
starting in sleep; transient flushes of. the face; an irritated, quick 
pulse, an occasional frowning expression of the countenance ; wake- 
fulness ; and grinding the teeth. In the second stage : more or less 
continued pain in the head; torpor of the bowels; nausea and vo- 
miting, particularly on assuming the erect posture ; irregular febrile 
exacerbations ; a peculiarly distressed expression of the countenance, 
sudden starting from sleep ; transient acute pain in the abdomen ; a 



INFLAMMATION OF THE BRAIN. 287 

circumscribed flush on one cheek ; mtolerance of light and sound ; 
hot and dry skin, with frequent, tense, and generally active pulse. In 
the last stage : constant somnolency; torpor of the intellectual func- 
tions ; strabismus ; paralysis of one or both upper eyelids ; more or 
less hemiplegia, coma, and convulsions. From infantile 7-emiltent, 
arachnitis differs in the great irregularity, both in relation to duration 
and time of recurrence of the remissions and exacerbations of the 
second stage. The appearance of the stools, too, will often assist us 
in the diagnosis between these two affections. In infantile remittent, 
the alvine discharges are fetid and of a dirty brown colour; in arach- 
nitis, they frequently have a glairy and dark green appearance. 
(Chcyne.) Dr. Coindet states that a micaceous deposition like crystals 
of boracic acid in the urine, is almost peculiar to hydrocephalus in 
its second stage. 

M. Gintrge (Journal GeneraJe de Medecine, 1825), gives the follow- 
ing, among a number of other diagnostic symptoms, between idiopa- 
thic arachnitis or cerebral fever, and infantile remittent, or fever from 
intestinal irritation. In idiopathic cerebral fever, the abdomen be- 
comes flattened; in infantile remittent, or fever from intestinal irrita- 
tion, from worms, &c, the abdomen is almost always tumid and hard. 
In the former affection, costiveness almost invariably attends, and when 
alvine evacuations do occur, they are generally green, slimy, or gela- 
tinous : in the latter disease, there is frequently more or less diarrhoea, 
the motions being brown, mucous and fetid. In idiopathic cerebral 
fever, the secretion of saliva is diminished : in fever from verminous 
irritation, it is generally increased. (Brera ) In cerebral fever, the 
tip and edges of the tongue are usually red : in fever from intestinal 
irritation by worms, the root and middle of the tongue are covered 
with a thick fur. In idiopathic cerebral disorder, the pain in the head 
is often extremely severe and continuous; in verminous fever, the 
pain is less severe, being obtuse and vague, the child seldom com- 
plaining of it as particularly distressing. In the former affection, the 
patient often directs his hand to the head : while in the latter," it is 
usually to the nose that the fingers are directed, in consequence of the 
itching there." In verminous fever, we often perceive a moment of 
deglutition during sleep, and hiccough, with occasional slight convuls- 
ive movements of the thumb and index finger. In the idiopathic 
cerebral disease, the nostrils are dry ; in fever from verminous irrita- 
tion, they are usually moist. In the former there is often a circum- 
scribed flush on one or both cheeks : in the latter, the face is commonly 
pale and leaden. In cerebral disease, the temperature of the head 
is above that of the abdomen : in intestinal irritation, the reverse 
obtains. In the former, the urine is small in quantity, red, and sedi- 
mentous: in the latter, it is sometimes clear and abundant; frequently 
whey-like, depositing a white sediment. 

Dr. Johnson very justly observes, however, that " there is no one 
pathological symptom, which can be depended on as characteristic 
of idiopathic cerebral fever, nor yet of the intestinal." Our conclu- 
sions must be drawn from the whole of the symptoms taken collect- 
ively. 



288 INFLAMMATION OF THE BRAIN. 

Dr. Alexander Monro has described a variety of hydrocephalus, 
which he calls the " hyper-acute form" of the disease, a form of very 
rare occurrence, and simulating, in some of its most striking symp- 
toms, inflammatory croup. " This rare form of the disease is very 
sudden- in its attack. There are no previous headache, drowsiness, 
stupor, nausea, vomiting, paralytic state of any part of the body, or 
any other symptom denoting a derangement of the functions of the 
nervous system. It begins like croup. The child awakens in the 
night in a stale of extreme agitation, and much flushed, and with a 
quick pulse ; he is hoarse, and the sound of the voice when he in- 
spires is similar to that of croup. The patient, at the onset of the 
disease, seems in a state of nervous irritation; often starts in his 
sleep, and in a short time the disease assumes the appearance rather 
of a spasmodic affection of the larynx than of the inflammatory croup. 
The matter thrown up by vomiting, consists generally of indigested 
food. The longer the disease continues, the shriller and hoarser the 
voice becomes." 

In the dissections which were made of children who died of " this 
form of the disease, Dr. Monro found in one instance, the vessels of 
the pia mater at the corpora quadrigemina and tractus optici, and at 
the origin of the eighth pair of nerves, much distended with blood. 
No morbid appearance was discovered in the larynx and trachea." 
In another case, " the upper part of the brain, particularly the supe- 
rior part of the posterior lobes, was covered with a transparent gela- 
tinous effusion ;" and about an ounce of coloured serum was found 
in the ventricles. " The vessels of the spinal marrow were turgid, 
those of the cervical portion of a vermilion-red colour, and those of 
the lumbar portion of a dark-red hue. The eighth pair of nerves 
was of a deep uniform red colour along its whole tract, as far as its 
branches, going to the lungs." 

Dr. Burns attributes this form of hydrocephalus " to an affection 
of the origin of the eighth pair of nerves, induced by the slate of the 
extremity of the fifth pair in dentition acting on its origin, which is 
near the eighth."* 

Post-mortem appearances. — In some cases the arachnoid mem- 
brane is minutely injected throughout its whole extent ; in others it 
is opaque and thickened. On its surface, " a purulent, sero-purulent, 
or sero-gelatinous exudation" is a very common phenomenon ; and 
it is still more common to find a greater or less portion of serum 
effused into the ventricles, between the lamina of the arachnoid, and 
into the cellular tissue between this membrane and the pia mater. 
(Martinet.) In some instances, however, little or no serum is found 
efiused. Out of twenty-six cases related by Martinet and Duchatelet, 
there were eight, in which scarcely any trace of eflusion into the 
cavities, or on the surface of the brain occurred. In some instances, 
the substance of the brain was altered in its consistence and colour ; 
and in a few cases the whole surface of the arachnoid was covered 
with a false membrane. 

* The Morbid Anatomy of the Brain. By Alexander Monro, M. D., 1827. 



INFLAMMATION OF THE BRAIN. 2S9 

Causes. — It would seem, that in some instances a bereditary or 
constitutional predisposition to tiie disease exists, I have known 
families, of which nearly all the children died during the period of 
dentition from arachnitis. It has been affirmed, also, that children 
of a scrofulous diathesis, are peculiarly liable to this afi'ection, an 
observation which appears indeed to be well founded. In general, 
children of an irritable habit, with weak or deranged digestive 
powers, seem to be most liable to this disease. Dr. Mills* states, 
that in a large proportion examined, the appearances of scrofula were 
evident. And Percival observes, that out .of twenty-two, eleven 
cases "were decidedly scrofulous."! 

Among the most common exciting causes, are: blows, falls, or 
other injuries of the head, causing more or less concussion ; insolation, 
[ictus solus;) suppressed habitual evacuations, or repelled chronic 
cutaneous eruptions; metastases of different kinds ; intense and long- 
continued mental application; the intemperate use of ardent liquors; 
the protracted influence of the depressing passions ; dentition, intes- 
tinal irritation ; hooping-cough ; cold, and in short, whatever is capa- 
ble of at once deranging the digestive organs, and causing a pre- 
ternatural determination of blood to the brain. The most conmiou 
cause of arachnitis during childhood, however, is the combined in- 
fluence of dentition, and intestinal irritation on the brain. If, while 
painfnl dentition is going on, the digestive functions suffer derange- 
ment from improper diet or some other circumstance, there will be 
two powerful causes of cerebral irritation and congestion present, 
which, under the general derangement of health which necessarily 
attends, will tend peculiarly to develop this fatal malady. Intesti- 
nal irritation is, indeed, very frequently the exciting, o-r perhaps, 
rather the predisposing cause of infantile arachnitis. The variable 
appetite; the irregular action of the bowels, and frequent unnatural 

* A Pathological Inquiry into the Nature of Hydrocephalus. By Thomas Mills, 
M. D., &c. Dublin Hospital Reports. 

t [It has long been understood that a scrofulous diathesis is peculiarly liable to 
hydrocephalus. Indeed, Dr. Cheyne suggested that the hereditary disposition to 
this disease is altogether derivable from that source. He also with Sprengel con- 
sidered hydrocephalus and scrofulous affections as mutually convertible into each 
other. Careful practitioners have always been influenced by this idea to refrain 
from repelling strumous eruptions, and of suddenly healing up ganglionic abscesses 
and fistulas in young children. Laennec and others pointed out the existence of 
granular tubercles in the cerebrum, cerebellum and spinal cord ; and the appear- 
ance of small opaque tuberculous masses along the course of the large veins of 
the pia mater and the longitudinal sinus, compared by some to the glands of 
Pacchioni, has long been recognized in hydrocephalus and other diseases of the 
brain. Dr. Gerhard, of this city, has lately called the attention of the profession 
to this subject more particularly, and gives strong countenance to the idea that the 
development of scrofulous tubercles is universal in the brains of hydrocephalic 
children. In conjunction with Dr. Rufz, in Paris, he derived this idea from an 
examination of about forty cases which terminated fatally in the children's hospi- 
tal of Paris. He proposes to denominate the disease tvbercular meningitis.— Mc] 
TOL. I. — 19 



290 INFLAMMATION OP THE BRAIN. 

appearance of the stools: the tumid abdomen and gastric tender- 
ness ; the picking and rnbbing of the nose, and the pale and sickly 
aspect of the countenance which so often precede the development 
of the disease, all point to the alimentary canal as the probable source 
of the primary irritation with which the brain sympathizes. When 
such gastric irritation exists, the supervention of any additional ex- 
citing cause, such as a severe fall, or blow on the head, painful den- 
tition, cold, &c., will often speedily develop this fatal malady. An 
interesting fact, corroborative of the observation that arachnitis and 
consequent effusion into the cavities of the brain are especially apt to 
result from intestinal irritation, is the circumstance that cholera in- 
fant itm, when it assumes somewhat of a chronic form, terminates 
not unfrequently in death, under all the characteristic symptoms of 
the last stage of hydrocephalus. In two instances of this kind, in 
which I had an opportunity of a post-mortem examination, I found 
the traces of arachnoid inflammation unequivocal, with copious serous 
effusion into the ventricles, and between the circumvolutions of the 
brain.* While we give all the importance to intestinal irritation, as 
a cause of arachnoid inflammation, which it unquestionably demands, 
we must bear in mind, that this same cause sometimes gives rise to 
a form of cerebral oppression, strongly resembling the last stage of 
arachnitis, but which is, nevertheless, wholly unconnected with 
cephalic inflammation. The determination to the head, in such 
cases, results merely in a state of strong venous congestion of the 
brain, giving rise to a somnolent and oppressed state of the system, 
which may be readily mistaken for hydrocephalus. (Clieyne.)t 

TreatrnenL — There are three principal indications to be kept in 
view in the treatment of arachnoid inflammation — viz. : 1, to mode- 
rate the general arterial action ; 2, to obviate the local congestion and 
inflammatory action in the brain ; and 3, to remove those causes of 
irritation which tend to keep up a preternatural determination of the 
blood to the head. 

When the disease becomes the object of medical attention in its 
early and incipient stage, the chief indication is to obviate local and 
general irritation, and to prevent undue determination of the blood 
to the head. With this view, the attention is to be particularly di- 
rected to the alimentary canal, for it is here that the primary irrita- 

* An interesting and striking case, in which hydrocephalic symptoms were 
produced by organic disease of the intestinal canal, is related in the Med. and 
Chir. Rev., July, 1826, p. 102. 

t Some writers contend, that hydrocephalus is almost invariably a sympathetic 
affection. Dr. Yeates, in particular, thinks that this disease has almost invariably 
its origin in the irritation of some organ remote from the brain, (a) Spurzheim 
admits that the primary irritation is frequently located in the abdomen; "yet 
anatomical dissections have convinced me,"' he says, '' that, in the greater number 
of cases, the morbid appearances of the abdomen are secondary of the cerebral 
disease." 



(a) Letter to Dr. Wall, kic.—Med. Chir. Journal^ Jan., 1819. 



INFLAMMATION OF THE BRAIN. 291 

tion and immediate cause of cephalic congestion most commonly 
exist. Laxatives are accordingly among our most valuable means 
for preventing the full development of the disease whilst it is yet in 
its incipient stage; and this is more especially the case in those in- 
stances which are attended with well-marked signs of intestinal dis- 
order. As the liver is usually inactive, or functionally deranged, in 
the commencement of the disease, calomel^ in small doses, succeeded 
by small portions of some of the milder purgatives, constitutes a very 
appropriate aperient in this affection. From one to two grains of 
this preparation should be given in the evening, followed next morn- 
ing with a weak dose of Epsom salts, or of powdered rhubarb, for a 
child of from one to five years old. In some instances of impending 
arachnitis, with manifest intestinal and hepatic derangement in chil- 
dren, I have derived much benefit by giving a grain of blue pill 
every evening, followed by a few drachms of castor oil in the morn- 
ing. The aperient and mercurial remedies should be continued daily 
until the alvine discharges exhibit a natural appearance. In addition 
to these means, the greatest attention must be given to the dietetic 
management of the patient ; for without an appropriate diet, little or 
no advantage can be derived from remedial treatment of this affec- 
tion. The most simple and unirritating articles of food alone must 
be allowed, such as boiled milk, barley-water, arrow-root, boiled rice, 
oat-meal gruel, weak beef or chicken tea, &c. 

When the arachnoid inflammation is once fully established, the 
plan of treatment should be promptly and decisively antiphlogistic, 
with revulsive and derivative application. Blood-leltins; ranks of 
course among our most efficient remedial means at this period of the 
disease, particularly when the inflammation is the consequence 
of some injury inflicted on the head, or where it results from gene- 
ral causes, such as cold. In such instances, the pulse is tense, quick, 
resisting and sharp; and in this case, the efficient abstraction of blood 
is indispensable. In those cases which arise sympathetically from 
disorder in the alimentary canal, the arterial excitement is not gene- 
rally very active. Here blood-letting, though usually indicated, must 
be employed widi more caution, for it is well ascertained that the 
copious abstraction of blood, by weakening the powers of vital re- 
sistance, greatly favours the morbid sympathetic affections arising 
from intestinal irritation— -(Armstrong, Marshall Hall, Travers.) In 
all instances, however, where the pulse indicates blood-letting, a suf- 
ficient quantity of blood should be taken away at once, to check, 
conspicuously, the activity and momentum of the circulation. After 
the symptoms of cerebral compression have ensued, sanguineous eva- 
cuations can be of little or no service ; nevertheless, should the arte- 
rial excitement and cephalic congestion be considerable, blood should 
be abstracted even in this advanced stage of the disease. 

With regard to the utility of local bleeding in this and other forms 
of encephalic inflammation, different opinions are expressed by prac- 
titioners. Nearly all the French writers on this disease are decidedly 
in favour of the local abstraction of blood. It appears, indeed, very 
reasonable to expect peculiar advantages from a mode of depletion 



292 INFLAMMATION OF THE BRAIN. 

which abstracts the blood more immediately from the affected parts; 
and yet, in relation to the present disease, a contrary opinion has been 
expressed by several eminent practitioners. Mr. North, in his work 
on the convulsive affections of infants, observes, " that he never found 
well-marked symptoms of determination to the head removed by 
leeches, however freely they were applied." In cases in which the 
cephalic determination depends on intestinal irritation, this obser- 
vation is no doubt well founded ; for the blood which may be thus 
removed from the capillaries of the head, will be immediately re- 
placed by the continued preternatural affiux of this fluid. It must 
be observed, moreover, that so long as the momentum of the general 
circulation is considerable, local bleeding can scarcely produce any 
other advantages than such as would result from abstracting the same 
quantity of blood by means of the lancet. General and adequate 
bleeding is, therefore, an essential preliminary to the beneficial em- 
ployment of leeches or cupping. After the impetus of the circulation 
has been moderated by the use of the lancet, leeching the temples, 
and along the posterior parts of the ears, is a valuable auxiliary in 
the treatment of arachnitis. Cupping is, perhaps, preferable to leech- 
ing in adults, for this operation seems to be better calculated to derive 
the circulation from internal inflamed parts than leeches. 

Purgatives are among our most useful means for subduing this 
disease. When the bowels are loaded with irritating substances, and 
the cerebral affection is symptomatic of intestinal irritation, laxativeis 
are, in truth, the main stay of our hopes. They are, indeed, almost 
equally useful in idiopathic arachnitis; for, besides their effect in 
evacuating irritating causes, they tend, very particularly, to diminish 
the afliux of blood to the brain, and to moderate the general momen- 
tum of the circulation. In cases depending on a primary irritation 
of the alimentary canal, the milder laxatives, afler the first thorough 
evacuation of the bowels by an active purge, should be employed in 
such a way as to keep the bowels in a relaxed state throughout the 
whole course of the disease. Repeated doses of the more active 
purges, though, at first, apparently useful in such cases, tend ulti- 
mately to increase the intestinal irritation, and consequently the ce- 
phalic affection. The first purge should be sufficiently active to eva- 
cuate the bowels well. Four or five grains of calomel, followed in 
a few hours by the occasional use of the infusion of senna and manna 
until free purging is produced, will answer well as a first purgative. 
The bowels must afterwards be regularly evacuated three or four 
times daily, by the use of small doses of calomel, promoted by castor 
oil and laxative enemata. It must be recollected that intestinal irri- 
tation is not always dependent solely on the presence of acrid or irri- 
tating matters in the bowels. The mucous membrane of the alimen- 
tary canal may be in a state of subacute inflammation, with more or 
less of abrasion, or perhaps ulceration. Under these circumstances, 
the milder laxatives are manifestly more appropriate than the more 
irritating articles of this class, since they are sufficient to evacuate the 
contents of the bowels, without causing injurious irritation. In idio- 
pathic arachnitis, however, the bowels are almost always very torpid, 



INFLAMMATION OF THE BRAIN. 293 

and can seldom be adequately moved, without, the employment of the 
more active purgative remedies. In cases, too, that are attended with 
a great accumulation of fecal matter in the bowels, brisk and frequent 
purgation is particularly necessary. " Should we ascertain," says Dr. 
Cheyne, " that the alimentary canal is torpid, and imperfectly per- 
forming its fnnctions, and admitting an accumulation of fecal matter, 
or that the secretions flowing into it are vitiated or diminished in 
quantity — circumstances which we ascertain by the peculiarity in the 
appearance or the pungent fetor of the stools, we must, by steadily 
pursuing the purgative plan, endeavour to affect a change ; for while 
this is produced in the appearance of the stools, we are affecting a 
more important change in the hepatic system of the alimentary canal, 
and of all the parts which are connected with them." 

Calomel should enter largely into the purgatives employed in this 
disease. From one to three grains, according to the age of the patient, 
may be given every two or three hours, until from ten to twelve 
grains are administered, and followed by a dose of infusion of senna, 
or sulphate of maguesia, or castor oil. In cases where there is reason 
to suspect the presence of worms in the bowels, anthelmintics should 
be employed in conjunction with purgatives. An infusion of spigelia, 
and senna may be used in such instances. The stomach, however, 
is often so extremely irritable in this disease, that no articles will be 
retained a sufficient time to operate on the bowels. Where this state 
exists, we must endeavour, in the first place, to allay the gastric irri- 
tability, and this may, in general, be effected by minute doses of calo- 
mel and ipecacuanha : the one-sixth of a grain of the former, in union 
with one-fourth or one-third of a grain of the latter, has repeatedly 
succeeded in my hands to restrain the tendency to vomiting in this 
disease. 

Mercury has been much recommended as a remedy in this affec- 
tion. One of the only two cases of recovery from apparently com- 
pletely developed arachnitis, which have occurred in my practice, 
appear to have been brought about by the mercurial influences. Drs. 
Percival, Dobson, Rush and Cheyne, mention cases which yielded to 
the powers of this article. Employed with a view to its constitu- 
tional influence, mercury often contributes very decisively to the re- 
duction of visceral inflammation, and experience has shown, that in 
the present affection, its powers are sometimes unequivocally bene- 
ficial. The best mode, perhaps, of employing mercury in this disease, 
with a view to its salivant operation, is in the form of friction with 
the ungt. hydrar. In whatever way mercurials are used, it is always 
extremely difficult in children to procure its salivant efiects. Almost 
the whole surface should be frequently rubbed with the mercurial 
ointment, where this effect is desired. 

Nothing is more common in the treatment of this disease than the 
application of blisters to the shaven scalp ; but this practice is, I con- 
ceive, of very doubtful propriety. I have always preferred placing 
them on the back of the neck or behind the ears, while ice or cold 
water is applied to the top of the head, and warm or rubefacient 
applications made to the feet. Dr. North, whose interesting work I 



294 INFLAMMATION OF THE BRAIN. 

have already mentioned, observes, "that blisters to the head are 
decidedly prejudicial in the convulsive diseases of infants ;" and the 
same observation is applicable, I think, to the disease under considera- 
tion. The application of ice or iced water, in the manner mentioned 
in the last chapter, may be accounted a very useful auxiliary in the 
treatment of arachnitis, and to favour its revulsive influence, warm 
or stimulating applications to the feet may be usefully employed. 
Dr. Regnault recommends, in very strong terms, the application of 
moxa in this complaint ;* and its known efficacy in subduing deep- 
seated articular inflammation, justifies the expectation of considera- 
ble advantage from its use in arachnoid inflammation. Neither this 
application nor bhsters, however, should be resorted to, until the 
activhy of the circulation is reduced by general and local blood-let- 
ting. The tartar emetic ointment, also, may be very beneficially 
applied. (Monro. )t 

Dr. Stocker,f of Dublin, speaks much in favour of the use of 
James's powder in hydrocephalic affections. He asserts that this 
preparation possesses peculiar powers to diminish the determination 
of the blood to the head; and of its tendency in this way, I have 
myself known several examples in other cephalic diseases. It may 
be conveniently given in small but frequent doses, in union with 
calomel, in this affection. Drs. Cheyne and Monro speak in equally 
favourable terms of this preparation in this dangerous disease. The 
latter states that he has cured several cases of this disease by a plas- 
ter composed of tartar emetic and wax ointment applied to the head, 
and the use of calomel combined with James's powder. This com- 
bination he says, is particularly useful in restoring the healthy action 
of the bowels. 

Dover's powder, also, has found advocates as a remedy in this 
disease. Drs. Brooke, Percival, Cheyne and Crampton,§ all speak 
favourably .of this employment in -hydrocephalus. After adequate 
depletion and purgation, in cases connected with intestinal irritation, 
small doses of this composition often prove serviceable, by allaying 
general irritability, and inducing a gentle diaphoresis. In the idio- 
pathic form of the disease, however, opiates of every description 
must be carefully avoided, as their tendency to increase the flow of 
blood to the brain could hardly fail to prove injurious. When pre- 
ternatural determination to the head depends on a remote focus of 
irritation — as in the mucous membrane of the bowels — opiates, by 
diminishing nervous excitability as well as local irritation, will occa- 
sionally reduce also the irregular determinations which depend on 
such irritations. It is in cases of this kind only that we may venture 
on the exhibition of Dover's powder, and not in these instances until 

* Medical and Physical Journal, vol. xl. p. 16. 

t [In the last stage of arachnitis, I am confident that blisters over the scalp are 
most advantageous. — Mc] 

% Dublin Medical Essays, anno 1806. 

k Transact, of the Associat. of Fellows and Licentiates of the Queen's Col- 
lege of Physic, in Ireland, vol. vii. 



INFLAMMATION OF THE BRAIN. 295 

the impetus of the circulation has been moderated, and the aUmen- 
tary canal well evacuated. 

It would seem, fromahe observations of Mr. Newnham, that 
green tea has a powerful tendency to lessen the morbid vascular 
action, not only of the system generally, but especially of the brain. 
" In the acute irritation of the membranes of the brain in children," 
he says, « the efficacy of green tea has been strongly marked in ray 
practice. Exhibited during the early symptoms, as soon as a suffi- 
cient quantity of blood has been taken, and before effusion occurs, it 
has proved a more powerful means than any other we possess, of 
controlling the morbid_ action, which, if suffered to proceed to its 
second stage, is scarcely to be overtaken by any treatment."* 



Sect. III._0/ Cerebritis— Softening of the Brain. 
{Bamollissement du cerveait.) 

This form of cerebral disease has of late been particularly investi- 
gated by the French pathologists. Recamier, I3ayle, Cayol, Briche- 
teau, Rostan, and Lallemand,t have published numerous and inte- 
resting observations concerning its symptoms and pathology. The 
disease, as it is manifested on dissection, consists of a softening or 
a kind of liquefaction of a portion of the cerebral mass, with vascular 
injection of the surrounding substance. Rostan divides the disease 
into two periods. 

The symptoms of the first period are : a fixed and violent pain in 
the head, often continued for several months ; vertigo ; obtuseness of 
the mental faculties; confusion of the ideas; and weakness and tem- 
porary loss of memory; questions are ansv/ered after long hesitation : 
and the patient appears at times dejected, querulous, and- wholly 
indifferent to surrounding objects. There is generally a sensation of 
tingling and numbness in the extremities of the fingers ; vision is 
often perverted, and in some instances, total blindness occurs at 
times. The hearing is almost always dull, but in some cases the 
reverse obtains, the sense of hearing being morbidly acute. Some 
complain of tenderness of the epigastrium, with constipation and 
variable appetite. The pulse is often full and hard, and sometimes 
intermitting. Occasionally, there is temporary delirium, with fisver 
and mnch agitation. 

The second period is characterized by the gradual or sudden super- 
vention of paralysis of one limb, sometimes of half the body ; but 
consciousness and intellect remain. Questions are now answered 
with very great difficulty, the patient generally expressing his desires 
by automatic movements. In some instances a complete state of 
coma occurs, followed occasionally with convulsions. 

In most instances, a sudden attack of convulsions is the first symp- 

* Med. Chir. Rev., July, 1827. 

t Recherches Anatomies Pathologiques sur I'Encephalite. PariS; 1820. 



296 INFLAMMATION OF THE BRAIN. 

torn that excites alarm. These convulsions often continue for many 
hours, followed, in some cases, with deep coma and a contracted 
state of the flexor muscles of the limbs. Occasionally, the parox- 
ysms of convulsions recur repeatedly at short intervals, " the patient 
being sensible in the intermediate periods, and complaining of head- 
ache, till after twelve or twenty-four hours, coma supervenes. From 
this state there is often a complete recovery for several days, when, 
without any warning, the convulsions return, and end in fatal coma." 

In a case which came under my care, the patient complained at 
times of a deep-seated pain in the head ; his memory for particular 
names and things was greatly weakened — so much so that he forgot 
the name of the street he lived in ; and was several times obliged to 
inquire the way to his own house, although but a square from it. 
He became taciturn, and uttered his words with a kind of hesitating 
doubt. He continued in this condition for five or six weeks before 
he was confined to his room. The pain, however, at length became 
very severe ; the pulse was very hard and strong ; the countenance 
flushed; and the bowels costive; but there was no delirium, and he 
experienced short intervals of perfect ease from the cephalic pain. 
After five or six days longer, double vision, great confusion of mind, 
and hesitancy of speech occurred, and at last deep coma, contraction 
of the extensor muscles of the forearms, convulsions, and death 
ensued. 

In this instance, the membranes of the brain did not exhibit any 
morbid appearances, except much vascular congestion. On slicing 
away the superior part of the brain, it appeared to be in a perfectly 
natural state ; on making a deeper section, however, three portions 
of the cerebral substance were discovered in a state of complete 
disorganization— being of a soft pap-like consistence, of a yellow- 
ish colour, and in one place of a darkish hue, as if dissolved blood 
had been mixed up with the softened portions of the brain. One 
of these disorganized portions was in the left posterior lobe of the 
cerebrum, and the other two near the corpora striata and thalami 
opticorum.* 

* [I made this post-mortem examination, and attended the patient in consulta- 
tion with the late Drs. Eberle and Parrish. It is stated correctly, with the omis- 
sion, however, that the cerebral substance was everywhere studded with red 
puncta under the knife, and exhibited the most decisive signs of long-continued 
vascular engorgement. My son and Dr. Leidy have this very day examined the 
body of a patient whom Dr. Bacon and I attended for some weeks before death, 
imder nearly the same symptoms. The left side had become totally paralyzed 
during the last two or three days, and the ramollissementwas found to be located 
in the right crus cerebri, and in the external portion of the adjacent thalamus 
opticus. The whole medullary substance of both hemispheres was of a dark or 
dusky hue, and studded with numerous and large bleeding puncta throughout. 
The pia mater was everywhere deeply loaded with blood, and tlie arachnoid in 
the fourth ventricle very much thickened and opaque. Indeed, I have never seen 
a case of ramoUissement that did not e.xhibit all the signs of vascular engorge- 
ment and cerebral inflammation. — Mc] 



INFLAMMATION OF THE BRAIN. 297 

The inflammatory nature of this softening of the brain has been 
much doubted by some. It has been supposed to be the consequence 
of a process similar to that which occurs in the softening of tubercu- 
lous matter in the lungs, and which, according to Laennec and some 
other writers, is siii generis, and wholly independent of inflamma- 
tion. The facts and arguments adduced by Lallemand, however, 
render the opinion of its inflammatory character, in most instances, 
at least, extremely probable. The writer thinks that the softening 
is the " efl'ect of inflammation arrested in its course by death, before 
purulent suppuration has had time to take place." 

It is most probable, as Dr. Abercrombie* observes, that this affec- 
tion occurs under two modifications, one unequivocally attended with 
cerebral inflammation, and the other a species of cerebral gangrene 
from defect of circulation, in consequence of a diseased state of the 
arteries of the brain — an opinion which, he thinks, is confirmed by 
the fact, that the peculiar softening of the brain mentioned by Ros- 
tan, as unconnected with symptoms indicating an inflammatory ac- 
tion, occurs almost exclusively in very aged individuals, inasmuch 
as ossification of the cerebral arteries is very common in elderly 
people. 

" In the cases of Rostan," says Dr. Abercrombie, " the disorgani- 
zation was observed chiefly in the external parts of the brain ; it 
occurred almost entirely in very old people, few of his cases being 
under sixty years of age, many of them seventy, seventy-five, and 
eighty. It was found in connection with attacks of a paralytic or 
apoplectic kind ; many of them protracted ; and was often found 
combined with extravasation of blood, or surrounding old apoplectic 
cysts. On the contrary, the atTection which I had been anxious to 
investigate, was found cliiefly in the dense central parts of the brain, 
the fornix, septum lucidum, and corpus callosum, or in the cerebral 
matter immediately surrounding the ventricles ; and occurred in per- 
sons of various ages, but chiefly in young people and in children. It 
took place in connection with attacks of an acute character, chiefly 
of the character of acute hydrocephalus ; and it was in many cases 
distinctly combined with appearances of an inflammatory character, 
such as deep redness of the cerebral matter surrounding it, suppura- 
tion bordering upon it, and deposition of false membrane in the 
membranous parts most nearly connected with it. We may even 
observe in different parts of the same diseased mass, one part in the 
state of ramollissement or softening, another forming an abscess, 
while a third retains characters of active inflammation, and probably 
exhibits, as we trace it from one extremity to the other, the inflamed 
state passing gradually into a state of softening. This is the infec- 
tion which 1 have endeavoured to investigate, and which I consider 
as one of primary importance in the pathology of acute affections 
of the brain, and which I cannot hesitate to consider as the result 
of inflammation." 

* Pathological and Practical Researches on the Diseases of the Brain, &c. By 
John Abercrombie, M. D. London, 1827. 



298 PNEUMONIA. 

One of the most characteristic phenomena of sof/ening of the brain, 
is a rigid contraction of the flexor muscles of the limbs. " Sometimes," 
says Lallemand, " this amounted only to simple rigidity of the limbs ; 
at others, it was carried so far that the patient's fist was kept rigidly 
applied to the shoulder and the heel to the buttock ;" and, contrary 
to what takes place in apoplexy, the mouth is drawn towards the 
paralyzed side. In general, the function of respiration remains en- 
tirely free from disorder, till within a few days of the fatal conclusion 
of the disease. 

The exciting causes of this form of cerebral disease are, no doubt, 
very various. Aneurism of the heart appears to be capable of exciting 
the disease. In many cases, says Lallemand, suppression of some 
habitual sanguineous evacuation preceded the attack of this affection ; 
the depressing mental emotions seemed, in some instances, to have 
favoured its occurrence ; and " many of the victims had been greatly 
addicted to the immoderate use of vinous and other fermented liquors." 
Dr. Johnson states that he has seen several cases which induce him 
to believe that "venojis congestion of the meninges of the brain has 
a very considerable effect in producing softening of the brain as well 
as sudden death."* I have seen a case of a pap-like and yellowish- 
brown disorganization of an internal portion of the brain, which 
occurred in consequence of a severe blow received on the head six 
months before the supervention of the disease. 

Treatment. — General and local blood-letting; sinapisms to the 
feet; cold applications to the head ; active cathartics; blisters to the 
back of the neck ; and calomel, with a view of its salivant operation, 
constitute the efficient means for combatting this formidable malady. 
Unfortunately, however, the disease often proceeds to a state of dis- 
organization before it becomes the object of medical attention, and 
then, of course, all remedial treatment must be abortive. 



CHAPTER XII. 

OF THE PHLEGMASIA OF THE RESPIRATORY ORGANS. 

Sect. I. — Pneumonia. 

The term pneumonia is employed, in a general sense, to designate 
acute inflammation within the cavity of the thorax, whether seated 
in the pleura, the mucous membrane of the bronchia, or in the pro- 
per substance of the lungs. The general characteristic symptoms of 
acute inflammation in the chest are: — cough, difficult and painful 
respiration, fixed pain in the thorax, and fever. Considerable difler- 

* Medico-Chirurgical Review, December, 1822, p. 485. 



PNEUMONIA. 299 

ence occurs, however, in the character of these symptoms, as well as 
in the other usual concomitant phenomena, according as the one or 
the other of these three structures just named is the principal or 
exclusive seat of the inflammation. Cullen was of opinion that the 
pleura can never be inflamed without an extension of the inflamma- 
tion to the pulmonary structure ; pleuritis, according to his views, 
being always accompanied with more or less of peripneumonic inflam- 
mation. Tlie observations of later pathologists,* however, have 
proved that the pleura is often exclusively inflamed, and that pleu- 
ritic inflammation is generally marked by symptoms sufficiently cha- 
racteristic to enable us to distinguish it from acute inflammation of 
the proper pulmonary substance. Without doubt pleuritis is very 
generally attended with inflammation of the subjacent tissues ; but 
its occasional separate existence is equally unquestionable. 



Pleuritis. — Pleurisy. 

In pleuritis, a violent and pungent pain is felt in the chest, gene- 
rally on one side, which is always greatly increased by a full inspi- 
ration, or on coughing. Respiration is hurried, short, and generally 
most oppressed when the patient lies on the affected side. The cough 
is short and dry, or attended with a glairy and nearly colourless sputa, 
and stifled as much as possible, to avoid the great increase of pain 
which it occasions. When the inflammation extends to the lungs, 
the expectoration is generally mixed with more or less of blood. The 
face is usually suffused with a vivid flush ; the pulse very hard, full, 
vigorous and frequent ; the tongue covered with a thick, white fur ; the 
skin hot and dry ; and the urine of a deep red colour, and small in 
quantity. The act of respiration is performed chiefly by the action 
of the diaphragm and abdominal muscles, the motion of the ribs 
being restrained by the patient, on account of the increase of pain 
which it always causes. 

Acute inflammation of the pleura is, however, not always attended 
by the foregoing unequivocal manifestations of its presence. In some 
instances, the disease, though rapid in its course and violent, is at- 
tended with scarcely any pain or cough. Baglivi mentions examples 
of this kind ; and Schmidtmann has given the history of several cases 
of what he cMs p/eur it is occult a A Mr. Tacheron gives an account 
of a fatal case, in which there was but liitle pain, and no cough, 
although the pleura was found, on dissection, coated with a yellow 
albuminous matter, a line in thickness, and a large quantity of fluid 
effused into the thorax.t Bichat also refers to the circumstance of the 
occasional absence of pain in the chest in acute inflannnation of the 
pleura. 

* Laennec. 

t Summa Obs. Med., vol. i. p. 108. 

t Rechexches Anatomies Pathologiques, &c. — Vide Med. Chir. Rev., March, 
1824. 



300 PNEUMONIA. 

Ca?/5e5.— Pleuritis is most apt to attack persons of a vigorous and 
plethoric habit of body. The influence of cold, when the body is in a 
state of perspiration from active exercise or confinement in a heated 
room, is its most common exciting cause. Pleurisy may also arise 
from metastasis of other affections— particularly of rheumatism, gout, 
and erysipelas; audit has been known to occur in consequence of 
suppression of the catamenial and hemorrhoidal discharges. 

Pleurisy from translated rheumatism or gout, is by no means an 
uncommon occurrence. I have met with a considerable number of 
cases of this kind, and one recently which was a strongly-marked in- 
stance. The patient was affected for several weeks with severe rheu- 
matic inflammation of the left elbow joint. A cold poultice was ap- 
plied to the joint in the evening, and on the next morning the pain and 
redness had in a great measure subsided. In the afternoon, a severe 
pain came on in the left side of the thorax, which rapidly increased 
in violence, and soon exhibited all the characteristic phenomena of 
pleurisy, whilst the pain in the elbow disappeared entirely. It was 
successfully treated with blood-letting, blisters, and the internal use 
of calomel and opium. In a few weeks after recovering from this 
attack, subacute rheumatic inflammation occurred in the elbow of the 
right side.* 

Pleurisy and depots of pus in the lungs are sometimes rapidly 
developed after capital surgical operations. M. Velpeau, in a very 
interesting memoir, has given the following as the result of his ob- 
servations on this subject: 1. " Those who die of acute diseases suc- 
ceeding surgical operations or profuse suppurations, generally fall 
victims to pleurisy, and the formation of abscesses more or less 
numerous in the lungs. 2. That the kind of pleurisy hitherto unde- 
scribed is of a peculiar nature, and might be denominated the pleu- 
risy succeeding surgical operations. 3. That this disease differs from 
simple pleurisy in the latency of its progress, the rapidity of its 
course, and the almost invariable certainty of its fatality. 4. That 
the pleurisy and formation of depots of matter are rarely accompa- 
nied by characteristic local symptoms sufficient to give notice of their 
existence." M. Velpeau ascribes these secondary pneumonic affec- 
tions to the absorption of pus, and its passage into the current of the 
circulation.t 

Post-mortem, appearances. — On dissection, the pleura is generally 
found uniformly red, or punctuated with small red specks of irregular 
shape and very close together. Laennec states that these red points 
" occupy the whole thickness of the pleura, leaving small intermediate 
spaces retaining the natural white colour." The pleura is not often 
found thickened in consequence of inflammation. Extravasation on 
the inner surface of this membrane is a never-failing occurrence in 
fatal cases of this disease. Laennec thinks that this extravasation 

* For much interesting information concerning rheumatic pneumonia, the reader 
is referred to Stoll's Ratio Medendi, &c. part i, p. 82 — and to Schmidtmann's Sum- 
ma Observ. Medicarum, torn, i, p, 62, et seq, 

t Revue Medicale, December, 1826, 



PNEUMONIA. 301 

commences with the inflammation. The matter thus thrown out hy 
the vessels of the inflamed pleura, consists of a semi-concrete or 
pseudo-membranous substance, or of coagulable lymph, or of sero- 
purulent fluid effused into the cavity of the chest. This fluid generally 
contains small flocculi or filaments of coagulable lymph, or of con- 
crete pus, and is either of a light yellow colour and nearly transparent, 
or reddish, as if a small portion of blood were mixed with it. Ad- 
hesions between the costal and pulmonary portions of the pleura 
occur in nearly all instances through the intervention of false mem- 
branous substances.* 

Prognosis. — Acute pleuritis is not, in general, a very dangerous 
affection- in subjects of a good and vigorous constitution. There is 
no inflammatory affection which is more under the control of an active 
antiphlogistic treatment. In subjects, however, of a weak habit of 
body — and especially in such as are predisposed to phthisis pulmo- 
nalis — pleurisy, if not a disease of much immediate danger, is to be 
dreaded on account of its tendency to develop pulmonary consump- 
tion. When the inflammation extends to the substance of the lungs, 
the patient may sink at an early period from effusion into, or disor- 
ganization of its structure. The following circumstances may be 
regarded as indicative of imminent danger in this afl'ection. A frequent 
eflbrt to sit up, particularly when there is a wheezing sound in the 
trachea, bloody expectoration,! and an obstructed pulse. The super- 
vention of diarrhoea is a most unfavourable sign ; convulsions and 
coma are no less ominous of a fatal tendency. Schmidtmann asserts, 
that he has never known an instance of recovery from this disease, 
after convulsions and coma had supervened. 

* The false membranes produced in pleurisy generally change after some time 
into a kind of cellular tissue, " or rather into a true serous membrane, like that of 
the pleura. This change," says Laennec, " is produced in the following man- 
ner: the serous effusion which accompanied the membranous exudation is absorbed; 
the compressed lung expands, and the false membrane investing it and the costal 
pleura become united in one substance. By degrees, this substance becomes 
divided into layers pretty thick and opaque, which are separated by a very small 
portion of serosity. About this time the blood-vessels begin to make their appear- 
ance in it, the first rudiments of which have the aspect of irregular lines of blood, 
much larger than the vessels which are to take their place. After a time the 
pseudo-membranous layers become thinner and less opaque: the lines of blood 
assume a cylindrical shape, and ramify in the manner of blood-vessels. Eventu- 
ally the layers of the false membrane become quite transparent, and nearly as 
thin as those of the ordinary cellular tissue. By degrees, it acquires the firmness 
of the natural cellular substance, and becomes the bond of a firm union between 
the lungs and the costal pleura." 

t Baalivi says, '^ Erectum sedere velle in morbis acutis pulmonum perijiciosum 
ac ferme lethale, pra^sertim. si adsit sibillus in aspera arteria, et difficultas excre- 
andi sputi, et licit cum talibus signis pulsum bonum videris, noli credere, nos fallit." 
Opera Omnia, p. 42. 



302 PNEUMONIA BILIOSA. 

Pneumonia. — Inflammation of the Lungs. 

When the parenchymatous substance of the lungs is the principal 
or sole seat of the inflammation, the disease is designated by the 
term peripneitmoni/. In this variety of thoracic inflammation, the 
breathing is much oppressed, particularly when the patient is in a 
horizontal posture; an obtuse pain is felt in the chest, generally in 
the region of the sternum, sometimes in the epigastrium, and occa- 
sionally in the side or scapular region. The cough is attended wiih 
a copious viscid expectoration, mixed more or less with blood. The 
skin is hot and dry ; the urine high coloured and scanty ; and the 
pulse frequent, full, obstructed, labouring, but rarely very hard; but 
in the advanced stage of the disease, it usually becomes weak, soft, 
obstructed and irregular. In violent cases, tending to efl'usion or 
disorganization of the inflamed portion of the lungs, the countenance 
acquires a hvid aspect, and the veins of the neck become turgid. 
The patient generally lies on the affected side, although, in some 
instances, the reverse position is preferred. " The sputa are white, 
slightly yellowish or greenish, somewhat diaphanous, and intermixed 
with bubbles of air. The tenacity of the matter expectorated is so 
great, that we may often reverse the vessel which contains it, and 
retain it in this position for a time without detaching it from its sides." 
Laennec regards this kind of sputa as pathognomic of this affection, 
"since it is the only one," he says, "that is found exclusively in it." 

In this, as in the former variety of pneumonic inflammation, the 
symptoms are sometimes so inconspicuous and equivocal in their 
character, that the true nature of the disease may remain doubtful, 
or be entirely mistaken, until fatal disorganization has occurred in 
the pulmonary structure. An instance of rapid fatal pneumonia is 
reported by Dr. Damiron, one of the physicians of the Hospital Val 
de Grace, in which no pain whatever was complained of by the 
patient, nor did epigastric pressure produce any uneasiness. The 
breathing was difficult, the cough frequent, the expectoration ropy 
and copious. On dissection, three-fourths of the right lung was 
hepatized, and the left lung was black and crepitous.* M. Andral 
has related seventeen cases, in which one or more of the characteristic 
signs of the disease were absent. In several instances, there was 
neither pain nor cough.t 

Pneumonia Biliosa. — Bilious Pleurisy. 

There is a modification of pneumonia, which from the prominent 
symptoms of hepatic disorder which it exhibits along with the ordi- 
nary phenomena of pneumonic inflammation, has been termed bilious 
pneumonia. This variety of the disease occurs during cold and 
variable seasons, in districts abounding in sources of miasmatic ex- 
halations. It appears to be the result of the combined agency of 

* Med. Chir. Rev., October, 1825. 

t Clinique Medicale, &c. Par G. Andral. Paris, 1824. 



PNEUMONIA BILIOSA. 303 

kohw-miasmata and atmospheric vicissitudes. The initial symp- 
toms of this modification of the disease differ very little from those 
which usually usher in an attack of ordinary bilious remittent fever. 
In some instances, a sense of fullness and tension is experienced in 
the right hypochondrium, a few days previous to the supervention 
of the disease, and occasionally dysenteric symptoms occur before 
the fever commences. In almost all cases, considerable pain is felt 
in the back and extremities during the premonitory period. The 
skin from the beginning is more or less tinged with bile, and the 
conjunctiva, especially, is often conspicuously icterode. The face is 
flushed, " and a sickly mixture of red and yellow, upon close ex- 
amination, betrays the existence of a disturbed state of the liver." 
(Potter.) Acute pain in the forehead is almost constantly present. 
The pain in the chest is sometimes extremely severe and pungent; 
but more commonly it is obtuse, and attended with a sense of weight 
or oppression in the breast. In some cases the lever continues for 
several days before the pectoral pain supervenes. The expectoration 
is not very copious— the sputa being of a frothy yellowish appear- 
ance, marked frequently with streaks of blood. The fever is gene- 
rally attended with manifest evening exacerbations and mornino- 
remissions. When vomiting takes place, an occurrence very cora° 
mon in this affection, more or less of bilious matter is generally 
thrown up, although, in some instances, the secretion of bile appears 
to be entirely suspended ; the ejections consisting of nothing else than 
gastric mucus and the ingesta. The tongue is at first white, with a 
yellowish streak along the middle, which, as the disease advances, 
becomes dark-brown and dry. The urine is always of a deep yel- 
low or bilious colour; and the pulse is generally small, frequent and 
quick, with a slight degree of preternatural tension. 

Post-mortem appearances. — The morbid structural changes pro- 
duced in the lungs by inflammation are : 

1. Engorgemeiit, the inflamed portion of the lungs exhibiting 
externally a brown mottled or violet colour, "■ which forms a strong 
contrast with the gray or pale rose-colour of the healthy part." It 
is of a firmer texture, and heavier than in the sound state — feels cre- 
pitous under the finger, though less so than in the healthy condition ; 
and on being pressed between the fingers, the air-cells will be per- 
ceived to contain a considerable portion of extra vasated fluid. When 
the engorged portions of the lungs are laid open with the knife, a 
large quantity of a frothy reddish serosity runs out, and the internal 
structure exhibits a livid and red appearance. If portions of the 
engorged lung are pressed until all the fluid has been squeezed out, 
they become as elastic and crepitous, and of the same colour as the 
healthy part, if air be blown into them. Simple engorgement ap- 
pears to be the result of the weakest grade of acute inflammation, 
and may even arise mechanically from mere sanguineous congestion 
during the last moments of life, or in articulo mortis. (Andral.) 
When the inflammation is intense, and terminates in the above en- 
gorged condition, the structure of the lungs is at the same time ren- 



304 PNEUMONIA BILIOSA. 

dered soft or friable,being readily broken down when pressed between 
the hngers. To distinguish mere engorgement by extravasated fluid 
from sanguineous cotigestion and engorgement from inflammation, 
we must judge less, says Andral, from the colour than the degree of 
firmness of the pulmonary structure. In almost every instance aris- 
ing from inflammation, the substance of the lungs is rendered more 
or less friable. 

2. Hepatization, presenting at first sight the appearance and con- 
sistence of liver. In this variety of structural change, the lung is 
impermeable by air, and is entirely deprived of its crepitous feel 
under the finger, and sinks when put into water. When cut into, a 
small portion of a reddish fluid issues, without exhibiting any frothy 
appearance. If we examine the incised surface with a lens, we per- 
ceive that the lung has lost its cellular structure — the pulmonary sub- 
stance exhibiting a red granulated appearance; and on being pressed 
between the fingers, is found to be readily broken down and reduced 
to a reddish pulp. (Andral.) When a lung is hepatized, its volume 
seems much greater than natural, " but this apparent enlargement is 
caused merely by the diseased lung not collapsing." This morbid 
condition has been called red hepatization. 

3. Gray hepatization. — This seems to be the result of a more 
intense degree of inflammation than that which gives rise to red 
hepatization. In the present morbid condition, the pulmonary struc- 
ture is granular, condensed, and impermeable to air, as in the preced- 
ing variety ; but its colour is grayish or yellowish pale, and when 
cut into, discharges copiously an opaque-yellowish or grayish fluid, 
which is manifestly purulent, and almost entirely without smell. In 
some cases, the pus does not issue spontaneously from the incised sur- 
faces, but on pressing the tissue moderately, small drops of purulent 
fluid are forced out. In this variety of disorganization, the pulmo- 
nary tissue is softened, and readily converted into a grayish pulp by 
pressure between the fingers. Acute inflammation of the lungs 
never terminates in induration of its structure ; this termination is 
peculiar to chronic pulmonary inflammation. According to Andral, 
there are two varieties of induration, the red and gray. 

4. Gangrene. — This is a very rare termination of acute inflamma- 
tion of the lungs. Andral gives an account of two instances of this 
kind. In a late number of the Journal Hebdomadaire, there are 
several cases reported, which terminated in gangrene of the pulmo- 
nary structure. These cases were attended with an intolerable fetid 
and gangrenous breath, particularly during the fits of coughing, and 
the matter expectorated was of a chocolate colour, and emitted a most 
offensive smell. On dissection, a considerable portion of the lung 
was found converted into a putrid mass, containing fragments of pul- 
monary texture, of a black or violet colour. The surrounding por- 
tions of lungs were infiltrated and partly hepatized. Dr. Chambers, 
also, has published some cases of gangrenous suppuration of the 
lungs, in which he refers particularly to the intolerable fetor of the 
breath as a diagnostic sign of this mode of termination. Andral 



PNEUMONIA BILIOSA. 305 

States, that at first the expectoration is a greenish liquid, then dirty- 
gray, at times reddish, and exhahng an extremely fetid smell.* 

The formation of abscess from pneumonic inflammation, is also a 
very rare occurrence. Both Laennec and Andral assert, that pulmo- 
nary abscess is atnong the most uncommon terminations of acute 
inflammation of the lungs. The former met with but four or five 
instances in several hundred cases which he examined ; and the latter 
writer states that he has met with one case only. 

Laennec observes, that " nothing is more uncommon than to find 
the inflammation confined to the superior lobes of the lung." This, 
however, is contradicted by the observations of Andral, who, in 8S 
cases, (bund 47 with inflammation of the inferior lobe, 30 of the 
superior lobe, and 1 1 instances in which the whole lung was aff'ected. 

Dif/^nosis. — The most important diagnostic signs between pleurisy 
and peripneumony are those obtained by percussion of the chest, and 
by pressure made on the abdomen. In peripneumony, percussion 
made with the extremities of the fingers brought together in a line, 
produces an obscure dull sound, which is best estimated by compar- 
ing it with the sound produced by percussion of the healthy side of 
the chest. In pleurisy, on the contrary, no diff"erence can be perceived 
in the sound produced by percussion of the two sides of the thorax. 
In peripneumony, firm pressure on the abdomen with both hands, so 
as to push up the diaphragm against the lungs, almost invariably 
excites cough, great oppression, and a sense of suffocation ; whereas, 
in pleurisy, no such effects result from abdominal pressure. " If, then, 
we find united in the same patient a clear sound of the painful side 
on percussion ; insensibility to abdominal pressure ; smalhiess and 
rapidity of the respiration ; an increase of pain on full inspiration ; 
particular uneasiness upon lying on the affected side ;t and, lastly, pain 
upon firm pressure of the intercostal spaces of the affected side, we 
have litile reason to doubt of the existence of pleuritic inflammation." 
(Roux.) 

Peripneumony is characterized by an obscure pain in the chest; 
great efforts at inspiration, in order to supply the suspended functions 
on one part of the lungs ; increased snff"ering on firm abdominal pres- 
sure, and a dull obscure sound on percussion of the chest. Difficulty 
of lying on the sound side is generally mentioned among the charac- 
teristic symptoms of peripneumony; but Andral asserts, that this 
observation is by no means generally correct. The most common 
position is on the back. 

Auscultation, or the employment of the stethoscope, lias of late 
years attracted much attention, as a means for obtaining a correct 

* Schmidtmann, in an account of a case of pneumonia which terminated in 
gangrene of the lungs, says, '' irapar sputes saniosis, fuscis, nigris, putentibusque 
reddendis." — Sam. Ob. Med., vol. i. p. 80. 

Cases of gangrene of the lungs are also reported by MM. Martinet and Reca- 
nxierin their Hospital Reports. — See Revue Medicale, for 1827. 

t This arises from the lungs pressing on the inflamed pleura when the patient 
hes on the affected side. 
VOL. I.— 20 



306 PNEUMONIA BILIOSA. 

diagnosis in pectoral diseases. Interesting information with respect 
to the particular condition of thoracic adections, is no doubt to be 
obtained from this mode of examination ; but it requires much care- 
ful experience before a sufficient tact is acquired to procure satisfactory 
information in this way. M. Andral, who has paid much attention 
to this subject, has given the following account of his experience in 
uusciillation in pneumonic inflammation. 

« No sooner does the pain and difficulty of breathing come on, than 
the ear, applied to the thoracic parietes, recognizes a notable modifica- 
tion in the nature of the noise heard at each inspiration, and as the 
inflammation advances, the noise undergoes fresh modifications, which 
indicate, with more or less precision, the situation and degree of the 
affection. The voice is also modified. 

" At the commencement of the disease, whilst the lung is in the 
state of simple inflammatory engorgement, the noise of respiration 
in the affected part loses its clearness, and is more or less mixed with 
the dry-rat lie, which Laennec terms crepiloris, from the resemblance 
it bears to the noise emitted by common salt when thrown upon hot 
coals. It also bears considerable resemblance to the peculiar noise 
occasioned by folding or doubling a piece of parchment. The noise 
of natural respiration is always altered and obscured by this raltky 
but is not always entirely masked or concealed by it. As the inflam- 
mation increases, the rattle becomes more and more manifest, until at 
length it entirely conceals the inspiratory murmur. The presence of 
crepitous rattle indicates engorgement, or the first stage of inflamma- 
tion ; and- so long as it continues, it shows that the inflammation (in 
a great part at least), has not advanced beyond the firt^t degree. From 
its greater or less intensity, and from its more or less strong admixture 
with the natural respiration, we may derive indications of tlie degree 
to which the engorgement extends, and whether it is passing into the 
state of hepatization or otherwise. Whilst the noise of natural re- 
spiration predominates over the crepitous rattle, we may conclude that 
the inflammation is slight ; but, if the rattle increases, and predomi- 
nates in its turn, until at length it completely masks the respiration, 
we may be certain that the inflammation is advancing, and that it is 
passing on to the second degree. 

"At a more advanced period, the crepitous rattle gradually ceases 
to be heard; and if the natural respiration then returns, we know the 
disease is subsiding; but if there be no respiratory murmur audible, 
or if the natural respiration is replaced by another kind hereafter to 
be described, we may be certain that the disease is becoming more 
serious, and that the lung is hepatized. 

" M. Laennec has established the fact, that, in many cases, when 
engorgement of the lungs is succeeded by hepatization, the ear applied 
to the chest yec/5 the motion of the thoracic parietes, but does not hear 
any respiratory noise, either natural or pathologic. We have often 
verified this statement; but we have also frequently observed, in the 
same stage of the disease, another very remarkable phenomenon, 
which appears to have escaped Laennec's attention. In certain cases, 
where the lung is in the state of red or gray hepatization, the noise of 



PNEUMONIA BILIOSA. 307 

respiration does not disappear, but is modified in a singular manner, 
and is evidently different from the natural kind. It seems as if a per- 
son placed near the auscultator's ear breathed forcibly through a 
brazen tube; there is at the same time a peculiar kind of resonance 
of the voice, wherever this kind of respiration is audible. The modi- 
fication of the voice is not properly either es^ophony or pectorilo- 
quisrn ; it approaches more nearly to that form of resonance which 
is observed in dilatation of the bronchia. Whenever cases presenting 
this double modification of the voice and respiration have proved 
fatal, dissection has constantly presented either red or gray hepatiza- 
tion, or pleuritic effusion, 

<-The explanation of this modification of the voice and respiration 
seems easy. It appears to us to depend upon the air not being able 
to penetrate farther than the large bronchial tubes ; and, for this 
reason, the phenomena are manifested, not only in puhnonary hepa- 
tization, but also where the lung is compressed by pleuritic effusion : 
and, in short, wherever the air is prevented reaching the air-cells of 
the lungs. 

<' Whilst auscultation of the diseased side affords the different signs 
already enumerated, the respiration of the healthy side is heard with 
much greater intensity than in the physiological state;— as if it were 
necessary for the heallhij lung to receive a greater quantity of air in 
a given time, in order to supply the deficiency of the diseased one. 

" When the inflammation occupies a circumscribed portion situ- 
ated at a distance from the surface of the lung, more especially a part 
of the base of the centre or of the root, auscultation teaches us no- 
thing concerning the seat or degree of the disease."* 

Prognosis. — A copious expectoration of a thick imiform yellow- 
ish matter is one of the first, and perhaps most encouraging indica- 
tions of a favourable turn of the disease. When this symptom occurs 
in connection with an increased flow of sedimentous urine, and 
gentle diaphoresis, we have good grounds for predicting a favoura- 
ble issue of the disease, more especially, if at the same time the 
oppression and pain in the chest alDate, and the cough is less trouble- 
some. When, on the contrary, the pain and oppression become 
more generally diffused throughout the thorax; when the cough is 
dry, or attended with dark or red liquid sputa; when, along with a 
sense of suffocation and great anxiety, the countenance and lips be- 
come livid, and the pulse soft, irregular, and labouring ; and, finally, 
when delirium, coma, or convulsions supervene, or a sense of cold- 
ness is felt in the interior of the body, whilst the surface is very 
warm, the danger is to be considered as very great. A rattling 
respiration, accompanied with lividity of the countenance, and a 
constant effort by the patient, to bare the breast and to raise his head 
and shoulders from the bed, are almost certainly fatal indications.t 
The supervention of diarrhoea, in this disease, is a very unfavourable 
circumstance. t The prognosis in pneumonia is nevertheless at- 

* Med. Chir. Rev., October, 1826, p. 514. 

t Richtcr, Specielle Therapie, band, i., p. 415. Baglivi Opera., p. 42. 

X Baglivi Opera., p. 35. Riverius, Praxis Medica, t. i., p. 72. 



308 PNEUMONIA BILTOSA. 

tended with considerable uncertainty. Instances of unexpected 
recovery occur, after the most dangerous symptoms have made their 
appearance ; and, on the other hand, death sometimes speedily su- 
pervenes, in cases apparently free from particular danger. 

Treatment.— Bo\h in pleuritic and peripneumonic inflammation, 
bleeding is the first and most important remedial means. The 
extent to which it is to be carried must be entirely regulated by the 
degree and obstinacy of the pain, and the state of the pulse. In 
pleurisy, we are generally obliged to abstract more blood than in 
peripneumonia, before the arterial reaction is sufficiently moderated. 
Whether the pleura or the proper substance of the lungs be the seat 
of the inflammation, however, a sufficient quantity of blood should 
be drawn at once, to make a very manifest impression on the pulse. 
The blood should be suffered to flow without any regard to mere 
quantity, until a diminution of the pain and oppression in the chest, 
as well as of the action of the pulse, ensues. If the action of the 
pulse and the pain increase again, more blood must be drawn, and 
again to the extent of producing a decided impression on the system. 
The hluod should be drawn in a full stream from a large orifice. 
In pleurisy it is sometimes necessary to repeat the venesection three 
or four times in the course of the first twenty-four hours, before the 
violence of the disease is broken down. More caution, however, is 
necessary in the employment of the lancet in peripnettmonic inflam- 
mation. Here, although prompt and very efficient blood-letting is 
decidedly beneficial, and without the least risk in the commencement 
of the disease, yet it is necessary to proceed with caution in the repe- 
tition of this measure, as the disease advances, lest dangerous pros- 
tration be induced. In violent attacks of peripneumony, the pulse is 
sometimes small, frequent, oppressed, and but slightly tense from the 
beginning of the disease. This state of the pulse may be owing to 
an oppressed or congested condition of the heart and large internal 
venous trunks ; but it depends, also, occasionally, on an impaired 
state of the vital powers, particularly in what has been called nerv- 
ous or typhoid pneumonia. In such cases a vein should be opened; 
and if the pulse rises while the blood is flowing, we may proceed 
with confidence in the further abstraction of blood. Should the 
pulse become still weaker, however, the bleeding must be imme- 
diately stopped. Richter observes, that where the pulse is small in 
the commencement of peripneumonia, the physician should place his 
fingers on the artery, and request the patient to make two or three 
strong inspirations, or to excite him to cough, by causing him to 
inhale the fumes of vinegar. If, by these exertions, the pulse be- 
comes fuller and more active, we may be assured, he says, that there 
is still sufficient energy in the heart and arteries to justify the ab- 

* " Plus una vice vidi IsEta morbi facie, et segroto atque adstandibus sibi gratu- 
lantibus, ex pneumonia subito mortem accidisse. At non raro etiam contrarium 
observavi: rebus ferme conclamatis et segroto ad stygis confinia posito, prudenti 
atque audaci medicatione cum e manibus libitinae evacisse. "—Sc/wndimann, Ob. 
Med., t. i, p. 25. 



PNEUMONIA BILIOSA. 309 

straction of blood.* The blood drawn in these affections exhibits a 
thick, sizy, or buffy coat, on the surface of a more or less cupped 
coagulurn; and so long as the blood exhibits this appearance, bleed- 
ing may be regarded as a proper measure. The disappearance of 
the bufly coat is not, however, to be considered as a certain indica- 
tion that blood-letting is no longer proper; for where the action of 
the pulse and the degree of pain in the chest are such as to indicate 
the propriety of further abstractions of blood, bleeding may be con- 
fidently employed, notwithstanding the absence of the buffy coat on 
the drawn blood. " Some practitioners," says Dr. Millar, " have 
directed blood to be drawn, till the sizy crust which generally covers 
its surface, disappears. But this rule is extremely equivocal : in 
some the blood puts on this appearance at the beginning ; in others, 
not till towards the decline of the disea.se, and sometitnes no crust is 
observed through the whole course of the disease. The only certain 
indication, therefore, arises from the mitigation or violence of the 
symptoms." Local bleeding by leeches seldom procures any particu- 
lar advantages in the early periods of these affections, beyond that 
which arises from its general depleting effects. i\fler the disease has 
been in a great measure subdued, and venesection is no longer indi- 
cated, leeching may no doubt be occasionally beneficial. In this case, 
small and repeated doses of digitalis, also, sometimes contribute ma- 
terially to the further reduction of the general and local inflammatory 
action. A half a grain, in union with six or eight grains of nitre, 
may be given every three hours, until its effects on the pulse or 
stomach are manifested. 

Although gentle aperients are decidedly beneficial in pneumonic 
inflammation, yet general experience goes to show that active and 
repeated purging is much more apt to prove prejudicial than useful. 
This is more particularly apt to be the case after free expectoration 
has been established. Before the complete establishment of the ex- 
pectoration. Dr. Johnson states that he has known purgatives very 
beneficial in common pulmonic inflammation. Dr. O'Halloran also 
employed active purges with advantage in pneumonia, among the 
British troops at Gibraltar. {Med. Repos., No. 8 ) Nevertheless, as 
a general rule, active catharsis may be regarded as improper, unless, 
perhaps, in the very commencement of the disease. Small doses of 
one of the purgative neutral salts, or of castor oil, may be given, from 
time to time, so as to keep up a regular but moderate action of the 
bowels; or laxative enemata maybe used with advantage for this 
purpose. 

Emetics are equally improper in pleurisy and in pcripneumony ; 
but in bilious pneumonia, they may be accounted as among our 
most useful curative means. Richter states, that in this variety of 
the disease, emetics will often remove the pain in the chest as by a 
charm; and Stoll makes the same observation. {Ration. Meden., t, 
i.) In the few cases of this modification of pneumonia in which I 
have prescribed, I have had the most satisfactory evidence of the 

* Specielle Therapie. band. \, p. 418. 



310 PNEUMONIA BILIOSA. 

Utility of emetics in its treatment. They generally bring on a uniform 
diaphoresis, promote expectoration, and allay the pain in the thorax, 
often almost immediately. They usually bring up an abundance of 
bilious fluid from the stomach. 

Cooling diaphoretics are very useful auxiliary remedies in these 
afi'ections. Nitrate of potash with minute portions of antimony, the 
pulvis antimonialis, and the muriate of ammonia, are the best arti- 
cles of this kind in the present diseases. Richter particularly recom- 
mends the last-mentioned article in the treatment of inflammatory 
pectoral afi'ections ; and my own experience coincides entirely with 
his observations concerning its usefulness. It may be given accord- 
ing to the formula mentioned under the head of intermittins; fever. 

With a view both of diminishing the action of the heart and arte- 
ries, and of promoting expectoration, nauseating doses of tartar 
emetic are generally highly useful. In Italy, large doses of this 
article are almost exclusively relied on in the treatment of pneumonic 
inflammation. Rassori and his followers make this the principal, 
and, in some instances, almost the sole remedy. They exhibit it to 
the extent of from a scruple to several drachms in twenty-four hours; 
and they assert that when given thus freely, it seldom excites either 
vomiting or strong purging, but always a most decided sedative or 
contra-stimulant impression on the sanguiferous system. M. Laennec 
speaks strongly in favour of large doses of this antimonial in acute 
pulmonary aflections. He asserts, that in cases treated solely by 
bleeding, the pulmonary engorgement, discoverable by the stetho- 
scope, continues much longer than in cases that are treated with large 
doses of tartar emetic. He thinks that, given to the extent of from 
twelve to twenty grains during the day, this article acts specifically 
in subduing inflammation, and powerfully promotes absorption.* 
Dr. Fontaneilles, of Milan,! whose experience confirms the observa- 
tions of Rasori on this subject, observes, that the power to sustain 
large doses of tartar emetic, depends wholly on the system being in 
a morbid condition ; for in a healthy state, or after the disease is 
removed, the ability of taking large doses of this medicine without 
injurious consequences, does not exist. It would seem, moreover, 
that the power of bearing large doses of antimony in peripneumony, 
varies in the different stages of the disease. It is greatest at the 
acme of the disease— being less prominent in the beginning and in 
the decline of the inflammation. Dr. Fontaneilles generally gives 
about twelve grains per day in the first stage of the inflammation; 
but after the disease has advanced to its acme, from a scruple to half 
a drachm are administered in the same period. If the medicine pro- 
duce active vomiting, the dose must be diminished ; but so long as 
the power of bearing it without great nausea or vomiting continues, 
the dose should not be lessened, although the symptoms of the dis- 
ease may be declining. 

Many practitioners have strongly recommended the employment 

* Revue Medicale, Mai, 1824. — Hospital Reports from La Charite. 
t Archives Generales, February, 1824. 



PNEUMONIA BILIOSA. 311 

o( calomel and opiu7ii in perlpneumonic inflammation ; and my own 
experience has furnished me with repeated examples of the iitiUty of 
this practice.* After the disease has continued for three or four 
days, and the action of the heart and arteries has been duly mode- 
rated by depletion, opium often does much good by allaying the 
pain and cough, and powerfully promoting a salutary expectoration. 
There is nothing to be apprehended from its stimulating effects. 
When given in combination with minute doses of tartar emetic, or 
with calomel, after adequate abstractions of blood, this article has a 
more decided tendency to increase the expectoration and complete 
the resolution of the disease, than perhaps any other internal remedy 
we possess. When the pain and cough continue to be troublesome 
after venesection has been efficiently practised, a grain of opium in 
union with two grains of calomel, given every three or four hours, 
will seldom fail to bring great and permanent relief Where, how- 
ever, the expectoration is free, and of a proper consistence, opium, if 
it be at all used, should be given in much smaller doses. One-fourth 
of a grain of this narcotic, with one-tenth of a grain of tartar emetic, 
or two or three grains of pulv. Doveri, may, under such circumstances, 
be given every four or five hours. In pneumonic inflammation from 
metastasis of rheumatism or gout, this article is especially beneficial. 
In siv;h cases it ought to be given in large and frequent doses— two 
grains with the same quantity of calomel every two or three hours, 
until the system is completely under its influence. Richter states, 
that when pneumonia is the consequence of repelled cutaneous erup- 
tions, of measles, scarlatina, or of irregular gout, camphor, given in 
combination with ipecacuanha and opium, is, in general, a highly 
useful remedy. After blood has been decisively abstracted, one grain 
of camphor in union with the same quantity of opium and two grains 
of ipecacuanha, will often, he says, remove the pain and cough as 
by enchantment. If the pain returns, the dose must be repeated. 

Expectorants may be employed with advantage after the violence 
of the inflammation has been reduced by blood-letting ; but the 
benefit to be derived from this class of remedies is, upon the whole, 
much less considerable than might be inferred from the known salu- 
tary influence of a free expectoration in this affection. In the early 
or active stage of the disease, all articles of this kind, with the ex- 
ception of tartar emetic, kermes mineral^^ or mucilaginous fluids, 

* •' Method! Ilamiltonianaj commendatio ab illustri Sam, Gottl. Vogel, (n) cujus 
auctoritatem tanti semper feci, me movit earn tentare; et tenlando edoctus sum 
ejus inventum et vulgationem magnum praxeos medica; esse incrementum. 
Prima pericula omnem longe superabaut expectationem meam; quare viginti 
abhinc annis et ultra non facile morbus infiaramatorios mihi obvenit — et mulli 
centeni mihi obvenere — cui opium et calomel faustissimo cum successu non op- 
posuissem," — Schmidimann, Sam. Obser. Medicar., t, j, p, 27. 
t R, — Kermes mineral, gr. xv. 
Extract, glycyrrh. gij, 
Aq, fontanae ^vij. 
Syrup, scillac giij. — M, S. Take a tablespoonful every two hours, 

(a) Handbuch der Pract Arzneywissenshaft, 4 ter, theil. s. 25, u. 231. 



312 PNEUMONIA BILIOSA. 

are liable to do mischief. When the violence of the disease has been 
moderated, and the inflammation is about terminating m resolution, 
opium with tartar emetic, as has just been mentioned, will, m gene- 
ral, assist materially in establishing the expectoration. An infusion 
of the rad. polygal, sweetened with honey, may be beneficially given 
during convalescence from pneumonic inflammation. The patient 
should be allowed the free use of demulcent drinks— such as barley- 
water, flaxseed-fea, or a solution of gum arabic, to which honey or 
currant jelly may be added. 

Blisters are among our most valuable means for subduing pneu- 
monic diseases. As soon as the firmness and activity of the pulse 
have been reduced, a large vesicatory should be applied over the 
region of the aff'ected part. Baglivi observes, that in some instances 
of pleurisy, great difficulty of breathing and suppression of the ex- 
pectoration occur about the fifth or sixth day. In such cases, two 
blisters, he says, applied to the inside of the thighs, will generally 
produce a favourable change in all the symptoms. Triller recom- 
mends the same practice.* 

In protracted cases of pleuritic inflammation, where symptoms of 
eff"usion are present, a combination of calomel, digitalis, and squills, 
has been found particularly serviceable.! I have found the diuretic 
mentioned under the head of chronic peritonitis, very useful under 
circumstances of this kind. (See p. 25^.) 

In cases that terminate in empyema, paracentesis thoracis is 
recommended; and we are not without a considerable number of 
examples of the successful performance of this operation, both in 
empyema and vomica. Dr. Samuel Colhoun, in his edition of Gre- 
gory's Practice of Medicine, states, that "he has known a case in 
which this operation had the happiest effect, though the opening into 
the cavity of the abscess was deep, and penetrated far into the 
lungs."! For similar instances of successful paracentesis thoracis, 

* De Pleurilide, p. 48. 

t B.— Calomel 9 i. 

Pulv. scillae Qij. 

digitalis Qi. 

Conserv. rosar. q. s. — M. Divide into twenty pills. S. Take one three 
times daily. 

X [Dr. Colhoun alluded to an operation which I performed many years ago in 
his presence. The discharge was in that case decidedly purulent, consisting of 
more than 30 ounces of pure globular pus. As it was not like the serous contents of 
a distended pleura, we concluded that the case was one of interstitial pulmonary 
abscess; and that it militated against Laennec's idea that such collections are 
always pleural. There was also much substance of a fleshy kind to penetrate 
with the trochar on the inner surface of the ribs, which induced Dr. Colhoun to 
conclude that I penetrated '•' far into the lungs." I have repeatedly performed the 
same operation since and evacuated pleuritic effusions after cutting through a very 
thick false membrane behind the intercostal space, which gave the same sensa- 
tion as my cutting into the substance of the lungs. The operation of paiacentesis 
after pleurisy has now become very comrnoUj and if performed before the luag 



PNEUMONIA BILIOSA. 313 

the reader is referred to the works of Werlhoff,* Donald Monroe 
Stoll,t Richter4 Hotfman,§ B. Bell, and Aug. Gott. Richter.|| M. 
Jowett has reported a very mteresting case of empyema successfully 
treated by this operation ;1[ and we might go on to cite many more 
instances of this kind. I have been thus particular in referring to 
authorities in favour of this operation in cases of empyema or Tho- 
racic effusion, from the equivocal manner with which it is spoken 
of by Dr. Gregory in his practice. " Paracentesis thoracis,'' he 
says, « is probably advisable in certain cases both of vomica and 
empyema ; but the observations of authors on this piece of practice 
are very scanty."** 

When there is reason to believe that hepatization of a portion of 
the lungs has taken place, benefit may still be obtained, in some in- 
stances, from external irritating applications. Frictions with tartar 
emetic ointment, or with an ointment made by mixin? two drachms 
of the white precipitate with an ounce and a half of lard, will answer 
well for this purpose. Setons, and caustic issues, also, are useful in 
cases of this kind ; or continued blistering with emplast. lyttx. In- 
ternally, advantage may probably be derived from small doses of 

has become greatly shrunken, is generally successfol. At all events, it enables 
the subsequent applications of blisters and mercurials to excite the reabsorption of 
flilse membranes on the pleura, and thus prevent a return of the effusion.— Mc] 
* Opera. Hanov., 1775, p. 775. 
t Ratio Medendi, vol. iii. p. 155. 

1: Chirurgische Bibliotheck, band. 3, s. 464. Band. 4, s. 476. Band. 6, s. 590. 
Band. 7, s. 311. Band. 8, s. 728. 
^ Unterricht von dem Collegium der Aertze in Munster. 
II Medico-Chirurg. Observations. 

H Med. Chir. Rev., July, 1826. M. Jowett observes, " I have twice very re- 
cently had occasion to resort to paracentesis of the thora.>:, in hopeless cases of 
effusion arising from pleurisy. In both instances, the operation was the means 
of prolonging, although it did not eventually save, the lives of the individuals." 
To prevent the admission of air into the cavity, M. Jowett recommends the 
operation to be performed in the following manner: ''Having made a small in- 
cision through the integuments only, in the place selected for the operation — 
which will, most commonly, be in the back, in the sixth or seventh intercostal 
space — thrust a small trocar carefully through the muscles and costal pleura- 
having withdrawn the trocar and left the canula in the wound, join a tube, con- 
nected with a Reid or Weiss' syringe to the canula, and slowly abstract the fluid 
by the syringe, continuing to work it as long as the piston moves freely, or until 
symptoms come on which render it necessary to desist. Then remove the ca- 
nula from the wound without previously separating it from the syringe; approxi- 
mate the edges of the integuments by plasters, and apply a compress to make it 
more secure." 

** "The history of the operation of paracentesis thoracis for empyema or hy- 
drothorax, would well deserve an article in a periodical journal. Kurt Spreno-el 
has given a most erudite history of this operation, from the days of Hippocrates 

to the close of the last century, occupying eighty-seven pages of letterpress." ■ 

Dr. JohnsoHj Med. Chir. Rev., vol. v. p. 273. 



314 CTNANCHE LARTNGEA. 

muriate of mercury in union with conium or belladonna. One-tenth 
of a grain of this mercurial, with from two to three grams of the 
extract of conium, may be given three times daily. Diuretics, also, 
have been recommended both in hepatization and in suppuration of 
the pulmonary tissue— more especially in thoracic effusion. When 
suppuration has occurred, the strength of the system should be sup- 
ported by digestible and nutritious diet, opium, or extract of conium 
— but the more diffusible stimulants must be avoided. 



Sect. II. — Cynanche Laryngea. — Laryngitis. 

Until within a comparatively recent period, laryngitis was gene- 
rally confounded with croup, to which, indeed, it bears a considerable 
resemblance. Boerhaave refers to this disease in section 802 of his 
aphorisms, and Van Swieten quotes a strongly-marked case from 
Tulpius.* More recently, Drs. Farr, E. Percival and Home,t have 
published interesting papers on the pathology and treatment of this 
severe and dangerous variety of cynanche ; and the chapter on this 
subject in Dr. Armstrong's work on typhus, may be advantageously 
consulted. 

The disease usually commences with the ordinary initial symptoms 
of inflammatory fever; the patient experiencing at first slight sensa- 
tions of chilliness alternating with flushes of heat. A feeling of sore- 
ness in the fauces, attended with more or less tenderness to pressure 
in the larynx, and uneasiness in swallowing, are among the first 
symptoms. The voice soon becomes changed into a thick, slightly 
hoarse whisper, and on strong inspiration, the air seems to enter im- 
pededly, as if it were forced through a very narrow aperture, and is 
attended with a hoarse, dull, hollow sound. On examining the fauces, 
they exhibit a pale red, tumefied, and oedematous appearance. The 
expectoration is not abundant, and consists almost wholly of saliva 
of a ropy character. The pulse is generally frequent, contracted, and 
tense ; but in some cases it is but very little disturbed. The face is 
for the most part pale, and the tongue white, punctuated with red 
points, and covered with a layer of transparent nuicus. When the 
disease is fully developed, deglutition is very difficult and painful, 
and apt to excite alarming and distressing paroxysms of suffocative 
breathing. The temperature of the surface is unequal, being higher 
than natural in some parts, and lower in others. One of the most 
peculiar and characteristic symptoms of this affection, says Dr. Arm- 
strong, is the inability of patients to cough out, as is done in pulmo- 
nic or catarrhal affections ; the attempt to do so resulting in a kind of 
suffocating effort, terminating " in a low, grumbling, and almost grunt- 
ing sort of noise in the throat." Respiration somewhat impeded from 
the onset of the disease, becomes more and more oppressed and labo- 
rious as the disease advances, with occasional violent and distressing 

* Observ, Medicar,, lib. i, cap. 57, p. 96. 
t Medico-Chirurg. Transact,, vol. iii. p. 268» 



CYNANCHE LARYNGEA. 315 

paroxysms of dyspncea, until at last, in unsubdued cases, death occurs 
by actual suffocation,* 

In some instances, laryngitis is as insidious in its approach as it 
is rapid and fatal in its progress. Mr. Porter knew two instances 
of young men who went to bed at night, without complaining of 
any illness, "and were found dead from this affection the next 
morning.'' M. Leveilie has reported a case of laryngo-bronchitis, 
which was so masked by erysipelas of the face, as to escape observa- 
tion until within a few hours of its fatal termination. t 

"The seat of this affection," says Mr. Porter, "is more in the 
cellular tissue, connecting the mucous membrane with the adjacent 
parts, than in the membrane itself, although this latter structure is 
very frequently found to have been inflamed." The epiglottis, rima- 
glottis, soft palate and larynx, are always tumefied and osdematous 
by inflammation and serous effusion into the submucous cellular 
tissue, so as to approximate the sides of the glottis and prevent the 
passage of air into the lungs. In some instances the inflammation is 
confined to the larynx, but it occasionally is found to have extended 
down the trachea and even into the bronchia. (Armstrong.) Porter, 
however, observes, " I can find no satisfactory examples of the in- 
flammation having extended beyond the larynx and into the trachea ; 
on the contrary, the chief intensity of the disease has been in the epi- 
glottis, which is found red, erect, thickened and swollen, and during 
life resembles a piece of raw meat." J In the case reported by Le- 
veilie, the inflammation was manifest from the larynx down along 
the trachea and in the bronchia. 

The inflammation has been known to terminate in the formation 
of one or more abscesses in the parts surrounding the larynx. Arm- 
strong mentions a fatal case in an old woman, in which "a con- 
siderable abscess was found between the muscles of the pharynx 
and the bodies of the cervical vertebrae." In some instances false 
membrane is found on the epiglottis, tonsils and trachea. 

Treatment —Laryngitis is to be regarded as one of the most 
rapid and dangerous aflections. It often terminates fatally in less 
than twenty hours, under the most prompt, energetic and judicious 
modes of treatment. Blood-letting is unequivocally indicated, and 
yet its effects in arresting the progress of the inflammation in this 
affection, do not appear to equal those it manifests in other varieties 
of tracheal inflammation. Dr. Armstrong asserts, that in one in- 
stance, "one hundred and sixty ounces of blood were drawn within 

* [•' This formidable malady has always existed, for you may trace examples of 
it, under various names, even in the writings of the ancients. But it is only in 
recent times that it has been singled out from the rest of the anginse. and made a 
separate object of study. It has numbered some distinguished medical men 
among its victims : Dr. David Pitcairn, Sir John McNamara Hayes, Sir George Tat- 
hill. The celebrated General Washington died of yXJ' —Waison s Lectures, p, 443.] 

t Gazette de Sante, 1827. 

t Observations on the Surgical Pathology of the Larpx and Trachea, &c, By 
Wm, Henry Porter, p. 98, 



316 CTNANCHE LARYNGEA. 

the space of six hours," by venesection and leeches, yet " so far from 
arresting the inflammation, the patient died withni twenty-four 
hours." In only one case out of six, he says, did blood-lettmg ap- 
pear to afford unequivocal advantage. It must be admitted, indeed, 
that bleeding does not often procure any prominent benefit m this 
affection ; and yet who would undertake to treat the disease without 
resorting to prompt and efficient depletion ? Dr. Beck, of New York, 
attributes the want of success of this measure in laryngitis to the 
inefficient manner in which it is usually employed. When carried 
to the extent of producing syncope, it is, he thinks, as likely to do 
good in this as in other inflammatory affections of the respiratory 
passages. My own experience does not, however, entirely confirm 
this observation. Nevertheless, blood-letting to the extent of pro- 
ducing faintins; must be regarded as an indispensable auxiliary in 
the treatment of this affection.* Leeches should be largely applied 
to the throat. Martinet has reported a case which terminated suc- 
cessfully under the employment of general and local bleeding and 
blistering. In the course of three days upwards of 40 ounces of 
blood were drawn with the lancet, and 110 leeches applied to the 
throat and back of the neck. Blistetnng the throat or the back of 
the neck, while leeches and emollient poultices are applied to the 
throat, will in general assist materially in the reduction of the dis- 
ease. Armstrong places more reliance on the repeated employment 
of antimonial emetics in this disease, than on any other remedial 
measure. After having found blood-letting and local applications 
ineffectual in the majority of cases that had come under his care, he 
was induced to try the effects of emetics, "given in repeated doses, 
till free and frequent vomiting was produced." He accordingly 
gave antimonial emetics in five cases, for which he was subsequently 
called to prescribe. " No circumstance in my professional life," he 
says, " ever gratified me more than the great and sudden relief which 
vomiting aflbrded ; in reality it removed all the urgent symptoms at 
the time, and being re-excited as soon as ever the slightest signs of 

* ['-How and when are we to employ the great remedy for acute inflammation- 
blood-letting? or are we to employ it at all? These are points concerning which it 
is quite necessary that our minds should be prepared and prompt to decide. If 
you look merely at the results of the recorded cases of this fearful complaint, you 
■wiU scarcely find an answer to the question. In some of them, copious bleeding 
appeared to save the patients ; in others, it was of no service, but rather seemed 
to accelerate their death. Sir John McNamara Hayes suffered two attacks of cy- 
nanche laryngea. In the first he was bled freely. Dr. Roberts, of Startford, in- 
forms us that the first bleeding was attended with considerable relief, the second 
also with manifest advantage, and by the third, his safety appeared to be ensured. Fif- 
teen years after, he died of the same disorder, for which he was again bled and 
leeched under the care of the late Dr. Baillie. Washington was largely bled and 
died. Again, Dr. Francis, of New York, recovered from acute laryngitis after 
copious venesection. It is evidently needful to consider and determine the circum- 
stances under which we are to use or to withhold the lancet." — Watson's Lectures 
p. 444.] 



CrNANCHE LARYNGEA. 317 

Stricture in the larynx returned, at last completed the recovery." In 
a well-marked case which 1 recently attended, in a child about four 
years old, blood-letting to the extent of about ten ounces, with a 
blister to the throat, and three active emetics, effected a cure. Pur- 
gatives must not be neglected in the management of this affection. 
Calomel either by itself in large doses, or in union with rhubarb or 
jalap, should be given so as to keep up a free action of the bowels. 
Some advantage may, perhaps, be derived from warm and stimu- 
lating applications to the feet, such as warm pediluvia or sinapisms. 
Dr. Good recommends the use " of gargles of ice water acidulated, 
and epithems of pounded ice applied externally," in preference to 
blisters to the throat. I have seen an instance of this disease in 
which the application of a solution of lunar caustic, by means of a 
soft pencil to the inflamed fauces, (as is recommended by Mackenzie 
in the somewhat similar affection, recently described byBretonneau, 
under the name of diphtherile,) was evidently beneficial. 

It is probable that the insufflation of very finely powdered alum 
into the fauces, (a practice successfully adopted by Laennec in cynan- 
che trachealis,) would prove beneficial in this affection. The pow- 
dered alum may be blown into the fauces through a small tube or 
quill. 

The operation of bronchotomy is recommended by some writers, 
where the remedies already mentioned do not make any effectual 
impression on the disease. " Besides the uncertainty that must pre- 
vail as to the precise nature of the motbid action that is going on in 
acute laryngitis, and the consequent hazard a practitioner will run of 
losing his patient, whilst he is attempting a treatment that may be 
unsuccessful, there are many reasons why he should in the present 
instance decide at once on the performance of bronchotomy. Thus 
it allows the organ in which th.e diseased action is situated to remain 
in a perfect state of repose. Considered as a wound, it adds nothing 
to the patient's danger; and as the relief it affords is, at least, for a 
time, complete, it imparts confidence to the surgeon, and allows him 
more leisure to examine the symptoms and adopt the remedies ac- 
cordingly. If, however, the operation be not early performed, it had 
much better be let alone altogether."* 

A highly interesting instance is related of the successful perform- 
ance of tracheotomy, m a case of laryngitis, by Dr. Crampton, in the 
fourth volume of the Dublin Transactions. Professor Regnoli, also, 
has reported two successful instances of this operation in chronic 
laryngitis. The acute form of the disease, he observes, sometimes 
terminates in chronic oedematous tumefaction of the epiglottis, and 
the mucous membrane of the larynx, with or without thickening of 
the submucous cellular tissue, which will ultimately render respira- 
tion extremely difficult, and even cause death by suffocation. Here 
bronchotomy is the only means of relief in our power.t 

* W. H. Porter. Loc. citat., p. 100. 

t Nuovo Mercurio delle Scienze Mediche. Mazo, 1829.— See Rev. Medicak, 
Juin, 1829. 



318 CYNANCHE TRACHEALIS. 



Sect. Ill— C7/nanche Trachealis.— Croup, Hives. 

Symptoms.— TKis disease sometimes comes on suddenly, and ac- 
quires the utmost degree of violence in the course of a few hours. 
More commonly, however, its approach is gradual, the first symp- 
toms being those of ordinary pulmonary catarrh. A dry and hoarse 
cough, with slight difficulty'of breathing, and a change of the voice, 
are generally the first intimations of its invasion. This very peculiar 
hoarse and rough cough, with its accompanying slightly oppressed 
breathing, continues sometimes, with occasional remissions, lor seve- 
ral days, before the disease assumes its characteristic form and vio- 
lence. More or less febrile excitement is generally present, from the 
very commencement of the disease. Sooner or later the respiration 
becomes more difficult and distressing; the febrile reaction rises 
higher ; the voice becomes more indistmct, whispering, or annulled ; 
slight pain and uneasiness are felt in, the larynx; and the cough be- 
comes more sonorous. The disease now advances rapidly to its state 
of full development, and all the symptoms acquire a most alarming 
and distressing degree of violence. The countenance is flushed; the 
eyes prominent, injected and heavy ; the pulse frequent, tense, and 
quick; the skin dry and hot; and the respiration extremely difficult 
and anxious. Inspiration is especially difficult, and accompanied 
with a very peculiar ringing or stridulous sound. The cough at this 
time is often quite dry ; but in some instances, there is a copious and 
very tenacious albuminoid fluid secreted in the larynx and trachea, 
from the very onset of the disease, and in all cases, this viscid secre- 
tion occurs in the advanced stage of the malady. If the disease 
be not checked in its violence and progress, the breathing acquires, 
at last, a degree of oppression inexpressibly distressing; the little 
patient manifests, in the expression of its countenance and actions, 
the utmost degree of anguish and suffering ; the head is thrown back- 
wards, and the mouth kept open : the eyes are half closed or cast 
about with an imploring expression for relief; the voice is extinct; 
the lips livid; the face pale and covered with large drops of sweat; 
sensibility rapidly diminishes; slight coma ensues; the extremities 
become cold and clammy ; and finally breathing stops and closes the 
agonizing scene. 

Such are the ordinary course and symptoms of this frightful ma- 
lady. Much diversity, however, occurs in relation to the degree of 
violence and rapidity of these phenomena. In some instances, not 
more than a few hours elapse between the commencement and fatal 
termination of the disease. In other cases, the symptoms proceed 
slowly to their acme, and the disease is protracted for many days, and 
occasionally even for several weeks, assuming a chronic character, 
without, perhaps, having at any time manifested a very alarming 
degree of violence. The ordinary period occupied by this disease, is 
from two to five days. 

Caitses. — Cynanche trachealis is one of those inflammatory affec- 
tions for which a predisposition appears not unfrequently to be con- 



CYNANCHE TRACHEALIS. 319 

genital. It is certain, at least, that the childi-en of some families are 
particularly predisposed to the disease, whilst, in others, it never 
makes its appearance. In what this predisposition consists, we can- 
not tell. To say that it depends on a peculiar organization of the 
mucous membrane of the larynx and trachea, may be correct ; but 
what these organic peculiarities are, it would be in vain to inquire. 
Besides this original or natural predisposition, there is another one 
much more universal and influential in its agency, namely, age. Cy- 
nanche trachealis is, indeed, almost peculiar to the age of cliildhood, 
being vastly more common in children between the first and fifth 
year of age than in the whole subsequent and anterior periods of 
life. It is, nevertheless, not wholly confined to the years of infancy 
and childhood ; for occasionally, though rarely, it occurs in adults, 
and sometimes eveu in very advanced age. Ttiis aptitude to the dis- 
ease in early childhood may depend, in part, on the peculiar condi- 
tion of the glottis or larynx at this age ; for, that there exists some 
peculiarity in this portion of the respiratory passage, during infancy 
and childhood, unconnected, probably, with mere size of aperture, 
is manifest from the characteristic voice, at this early period, and its 
remarkable change during the period of pubescence. But there is 
another circumstance which may liave a large share in the so com- 
mon occurrence of this malady during infancy, namely, the almost 
universal custom of dressing children so as to keep the neck and upper 
part of the thorax perfectly bare,and thus rendering them more hable 
to the injurious influence of cold in these parts. Certain exanthema- 
tous aflections, also, olten give rise to an increased aptitude for this 
disease. This is especially the case with scarlatina, measles and 
miliary fever. Observation would seem to show that florid, robust 
and fat children are much more liable to the disease than those who 
are of an opposite habit. 

The principal exciting cause of this disease, is cold or sudden 
vicissitudes of atmospheric temperature; and hence its greater pre- 
valence during the variable, damp, and cold months of autumn and 
spring, than in the more temperate and uniform season of summer. 
Cynanche trachealis is said to have prevailed epidemically; but con- 
trary to what obtains, in this respect, with epidemic catarrh, these 
epidemic cynanche are,always, of a very limited sphere, with regard 
to the extent of country which they embrace. In general, this dis- 
ease is most apt to prevail after, or during the prevalence of measles 
or scarlatina. During convalescence from these aflfections, there exists 
an especial aptitude to cynanche from the influence of cold. It would 
seem, too, that the liability to this disease is often considerably in- 
creased, by having suffered an attack of it. I have known the same 
individual suffer five or six attacks of the disease, during the period 
of childhood. 

Cynanche trachealis is a phlegmasia! disease, consisting essentially 
of inflammation of the mucous membrane of the superior portion of 
the respiratory tube. The correctness of this pathology is confirmed 
not only by the known character of its most common exciting cause, 
but especially, also, by the more direct evidence of the symptoms of 



320 CTNANCHE TRACHEALIS. 

the disease, and the appearances discovered on post-mortem exa- 
mination.* 

The observations of Bretonneau in France, and of Mackenzie in 
England, published within a few years past, go directly to the esta- 
blishment of this view of the nature of the disease. Both these 
observers assert that the inflammation often commences in the fauces 
and on the tonsils, and descends thence into the trachea ; a progress 
of the disease, which may be verified by ocular inspection. I have 
myself seen several cases of croup, which commenced by a kind of 
erysipelatous or superficial inflammation, about the tonsils and soft 
palate ; and in one instance, this inflammation continued for four 
days, and was the object of medical attention before it extended into 
the trachea and gave rise to the symptoms of croup.t The inflam- 
mation which occasions the characteristic phenomena of this disease, 

* [Although croup consists essentially in an inflammation of the lining mem- 
brane of the trachea, (i. e., in the part below the larynx and above the bifurca- 
tion into the bronchi,) the disease sometimes extends higher up so as to affect 
directly the larynx, and still more frequently lower down so as to occupy the 
extreme ramifications of the bronchi. When the inflammation does not extend 
upwards into the larynx, the muscles of the glottis may nevertheless be thrown 
into spasmodic contraction by reflex sympathy. Dr. Watson, in his lately published 
lectures, makes the following excellent observations. " CuUen makes no dis- 
tinction between cynanche trachealis and cynanche laryngea. Yet they are 
separated from each other by very definite boundaries. They differ in anatomi- 
cal position; they differ in gravity. Both, indeed, are serious diseases, but croup 
is the more serious, because it seldom admits that mechanical relief (tracheotomy), 
which, when rendered in time, deprives cynanche laryngea of its dangerous cha- 
racter. The two disorders diffigr also in respect to the period of life at which they 
occur. Idiopathic laryngitis is seldom met with except in aduUs, croup seldom 
after the age of puberty. Cynanche trachealis is, indeed, a very remarkable dis- 
ease, — for it exhibits an event of inflammation which does not usually belong to 
that process when it affects the mucous tissues. In this, too, it differs from laryn- 
gitis. I say that croup is peculiarly a disease of early life. The interval that lies 
between the two periods of weaning and puberty is the time during which its 
visitation is chiefly to be apprehended. Comparatively few cases of it occur during 
the first year of infantile life. There are more in the second year than in any 
other." — '' Some of the cases recorded of croup in the adult, were probably in 
reality cases of laryngitis. It is curious that inflammation should thus at different 
epochs of life fix itself upon limited portions of the same continuous surface, and 
give rise to consequences so diverse. We are unable to give any account of this." 
— Mc] 

t It is surprising that a disease so manifesfly phlogistic in its character, should 
still be viewed by some of the German and French writers as essentially spas- 
modic in its nature, or at least, as wholly independent either of a local or gene- 
ral inflammatory condition. Several of the late continental writers on this dis- 
ease regard the fever and inflammation, which they acknowledge sometimes to 
exist, as wholly accidental, and as in no manner essential to the perfect constitu- 
tion of the malady. Among the principal antiphlogistic pathologists, in relation 



CYNANCHE TRACHEALIS. 321 

rarely remains confined to the larynx and trachea. In many instances, 
it extends downwards into the bronchia, and sometimes even into 
the small ramifications, giving rise to the simultaneous existence of 
acute bronchitis and laryngeal inflammation. The danger from this 
disease is always greater, cxteris paribus, in proportion as the in- 
flammation passes down into the bronchial ramifications. Indeed, 
when bronchitis coexists extensively, the result must almost inevita- 
bly prove unfortunate. 

In some instances, the laryngo-tracheal inflammation terminates, 
after a shorter or longer period from its commencement, in tlie for- 
mation of a false membrane ; which, according to the latest and most 
accurate observations, appears to consist of a concrete albuminoid 
secretion.* In other instances, the inflammation terminates in the 
secretion of a muco-purulent matter of an opaque and yellowish ap- 
pearance, without the formation of a pseudo-membranous substance. 
There are other cases, again, and these are perhaps much the most 
common, in which the inflammation produces neither false membrane, 
nor a puruloid matter, but an extremely copious secretion of a very 
viscid, limpid, and frothy mucus.t M. Bland, in his excellent work 
on this disease, maintains that these different modes of termination 
constitute good grounds for dividing the disease into three principal 
varieties, indicating three different grades of inflammation. The in- 
flammation, he says, is at the highest grade of violence, in those cases 
which are attended with the formation of false membrane. It is less 
violent in the instances where there is ovAj a muco-purulent fluid 
formed ; and in those cases in which a copious secretion of a tenacious, 
limpid, and frothy mucus occurs, the inflammation is at its lowest 
grade. In the first and most aggravated variety of the disease, the 
cough and respiration are always dry, or free from that peculiar rat- 
to this affection, may be mentioned Des-Essartz, Banafox, (a) Ruette, {h) 
Schneck,(c) Lobstein.(f/). Professor Nasse regards impaired or disturbed func- 
tion of the pneumogastric nerves, as the proximate cause of the disease. The 
symptoms which characterize this disease, he asserts, bear a very strong resem- 
blance to those which result from the division of the eighth pair of nerves. The 
inflammation which occurs in the mucous membrane of the respiratory passages, 
is, according to his views, secondary, and the consequence of the disordered 
function of the pneumogastric nerves. 

* According to the experiments of Schwilgue, this membranous substance is 
insoluble both in cold and in boiling water, but perfectly soluble in a solution of 
the alkalies. By incineration, it yields deuto-carbonate of sodium, proto-phos- 
phate ofhrae, &c. ; corresponding, thus, entirely with the properties of coagulated 
albumen. 

t Nouvelles Recherches sur la Laryngo-Tracheite. Par P. Blaud. A Paris, 
1824. 

(a) Journ. de Med. Chir. Pharm., &c., tom. xxxvii. November, 1816. 

(6) Traite de 1 'Asphyxia connue sous le nom de Croup. 

(c) Bib. Med., tom. xli, p. 256. 

{(i) Mem. de la Societe Med. d'Emulation, 8° annee, 2e part, p. 538. 

VOL. I. 21 



322 CYNANCHE TRACHEALIS. 

tling sound in the respiratory passages, which occurs, when these 
contain viscid secretions. This dryness of the cough usually continues 
for many hours after the disease is fully developed. The pain in the 
larynx is often very considerable, and the febrile reaction is generally 
violent. The per'iod at which the false membrane is formed, after 
the commencement of the inflammation, appears to vary considerably. 
In some cases M. Blaud found the larynx and trachea lined with snch 
a membranous substance, although the whole course of the disease 
did not occupy more than twenty hours; in other instances, several 
days appeared to elapse before it was formed. Occasionally, only a 
part of the internal surface of the larynx is found coated with this 
concretion ; but in some instances, it has been found to extend into 
the bronchia, and even into the smaller divisions. Sometimes, instead 
of a membranous expansion, we find, on dissection, the upper part 
of the trachea almost entirely blocked up by a thick mass of the 
concreted albuminoid secretion, lodged just within the glottis. 

In cases in which this membranous substance is not formed, the 
cough early becomes somewhat humid, and the respiration rattling ; 
and before the disease has continued many hours, the mucus in the 
larynx and trachea is so copious as to threaten suffocation by obstruct- 
ing the glottis. M. Blaud thinks that the extremely viscid mucus 
which is formed in these milder cases, is entirely different in its pro- 
perties from the secretion which occurs in the former variety — and 
that it is incapable of being so inspissated as to give rise to a pseudo- 
membranous substance. 

Whatever may be thought of M. Blaud's division of this disease, 
or of his sentiments in relation to the radical distinction between the 
inflammation and secretion which give rise to membranous structures, 
and that inflammation and its consequent mucoxisi secretion which 
occur in cases unattended with the formation of false membrane, it 
must be admitted, that there exists at least a twofold diversity in re- 
lation to the immediate local consequences of the laryngo-tracheal 
inflammation— namely, one variety in which false membrane is formed, 
and in which the cough and respiration are at first dry, or do not in- 
dicate the existence of much mucus in the respiratory passages ; and 
another variety in which the cough and respiration are humid, in the 
early period as well as throughout the disease, and in which a very 
copious secretion of transparent and extremely viscid mucus occurs. 
The former are exceedingly dangerous, nay, almost hopeless, unless 
subdued by the most prompt and powerful antiphlogistic measures, in 
their very onset. The latter are much less dangerous, and may gene- 
rally be cured by more moderate antiphlogistic measures, and the 
expulsion, from time to time, of the tenacious mucus from the larynx 
and trachea. 

In nearly all cases, the mucous membrane of the larynx and tra- 
chea is found very manifestly congested on dissection ; and the glottis 
is frequently considerably narrowed by a kind of thickening or tume- 
faction of its lips. 

With regard to the ratio symptomatum, it may be observed, that 
the immediate cause of the distressing difficulty of respiration, and 



CTNANCHE TRACHEALIS, 323 

finally of death, consists in an obstruction to the passage of the air 
into the lungs. The circunristance which causes the exckision of the 
air from the lungs consists either in a spasmodic closure of the glottis, 
or, in an occlusion of this aperture by tumefaction of its sides, or, by 
the formation of false membrane or a mass of concrete lymph, or. 
finally, by an excessive quantity of a very ropy and viscid mucus 
closing up the passage. Death is also sometimes the immediate con- 
sequence of a copious serous effusion into, and consequent choking 
up of, the bronchial cells, a mode of termination which almost al- 
ways occurs when the inflammation descends into the bronchial rami- 
fications. Spasmodic contraction and closure of the glottis may be 
caused by irritation excited by the upper portion of the false mem- 
brane. 

Prognosis. — Laryngo-tracheitis is always to be regarded as a very 
dangerous affection. Formerly the majority of cases terminated fa- 
tally ; but under the present improved pathology and mode of manage- 
ment, the proportion of fatal cases is greatly diminished. Frightful 
and unmanageable as this disease is, when suffered to pursue its 
course uncontrolled, or when opposed by inadequate means, it is, ne- 
vertheless, almost as much under the dominion of a prompt and vigo- 
rous antiphlogistic treatment, as any of the more serious phlegmasial 
affections. The degree of danger appears to be proportionate to the 
violence of the inflammation, and the extent to which it may have 
passed downwards into the pulmonary passages. It would seem, 
also, that the more sudden the attack, when attended with strong 
febrile excitement, the greater, in general, is the danger. When, how- 
ever, the disease supervenes suddenly without fever, the attack may 
be presumed to be purely spasmodic * and may readily yield. The 
shriller and more sonorous the cough, the more reason is there to ap- 
prehend danger. It must be observed, however, that the prognosis 
in this disease is often exceedingly fallacious. Sometimes the symp- 
toms yield, and promise a speedy convalescence, when a violent ex- 
acerbation will suddenly supervene and destroy the patient ; and on 
the other hand, death may appear to be impending, when on the 
sudden expulsion of a membrane, or even without such an occurrence, 
a rapid change for the better will ensue, and lead on to full conva- 
lescence. 

Diagnosis. — There is but one disease which may be mistaken for 
laryngo-tracheitis, namely, spasmodic or cerebral croup. From this 
latter form of disease it may be distinguished : by, 

1. The attack of cynanche laryngo-trachealis generally coming on 
gradually, with the ordinary initial symptoms of catarrhal affec- 
tions; spasmodic croup always supervenes sudde nil/, and is rarely 
preceded by catarrhal symptoms. When the former does come on 
suddenly, which is sometimes the case, it is so manifestly a febrile 
affection, that, by this circumstance alone, it may be readily distin- 
guished from the spasmodic disease. 

* llnder the head of Asthma, in the second volume, some observations are 
made on Spasmodic Croup. 



324 CYNANCHE TRACIIEALIS. 

2. Cynanche is essentially a febrile affection; spasmodic croup is 
free from fever, except it be acciSentally present. 

3. Cynanche is often attended with considerable remissions, but 
not with complete interinissions, except perhaps immediately after 
vomiting. Spasmodic croup is, often, marked by complete inlermis- 
siois, of considerable duration, 

4. Cynanche is always attended with a hoarse and sonorous cough, 
and frequently with a copious secretion of viscid mucus in the tra- 
chea. Spasmodic croup is rarely accompanied with much cough, fre- 
quently none at all, and it is always dry.* 

5. The peculiar stridulous sound of the cough and inspiration, so 
characteristic of cynanche laryngo-trachealis, does not occur in spas- 
modic croup. 

6. In spasmodic croup the pulse is small and contracted, and the 
skin not above the natural temperature. In cynanche, the pulse is 
excited and irritated, being generally full, frequent, quick, and 
tense ; and the temperature of the surface is febrile, except towards 
the fatal conclusion of the disease, when, from the imperfect func- 
tion of respiration, animal heat ceases to be generated in its normal 
proportion. 

Treatment. — From what has been said above of the nature and 
character of this disease, it is obvious that the general indications to 
be kept in view in its treatment are: 1, To subdue the local and 
general inflammatory action as speedily as possible ; and, 2, to pro- 
mote the discharge of the viscid and coagulable secretions which are 
lodged within the superior portions of the respiratory tube. For the 
fulfilment of the former of these indications, the most prompt and 
energetic antiphlogistic measures must be adopted. He who loses 
sight of, or neglects this all-important indication, and places his hopes 
in one or more of the empirical remedies that have, by different prac- 
titioners, been extolled for their supposed specific tendency to coun- 
teract the tracheal affection, will, we maybe confident, have but little 
reason to flatter himself for his success in the management of this 
malady.t 

The remedy upon which we must place our principal reliance for 

^ Dr. Rush has published an account of a dissection of a child that had died of 
spasmodic croup. In this subject, no membrane, nor even mucus was found in 
the resphatory passages, nor did the lungs exhibit the slightest traces of previous 
disease. 

t It was owing to physicians not attending to the essentially infiammatory 
nature of this affection, and the consequent indispensableness of prompt and 
vigorous antiphlogistic measures, that this disease was formerly so much more 
frequently fatal than it appears now to be. It is also owing to this error, or rather 
to the erroneous views which have been so common concerning the pathology of 
this disease, that so many physicians have objected to the employment of blood- 
letting, and expressed their willingness to confide in mercury ^ polygala senega, car- 
bonate of ammonia, and hepar sulphuris, to the exclusion of the direct and powerful 
antiphlogistic means, long since so vmiversally arid so successfully practised by 
American physicians. 



CYNANCHE TRACHEALIS. 325 

the reduction of the tracheal inflammation is blood-Jetting, in con- " 
junction with external vesicating or irritating apphcations to the 
throat. Here, liowever, as in most of the other phlegmasial diseases, 
the good eft'ects of the lancet are confined to the early period of the 
disease. If bleeding be neglected, or inefficiently employed, in the 
first stage of the malady, its progress will be extremely perilous, 
whatever other remedial measiu'es may be adopted. When called 
to a patient labouring under this disease, in whom the manifestations 
of high febrile excitement and active tracheal inflammation are con- 
spicuous, a vein should be opened, and the blood suffered to flow 
until an approach to syncope is induced. As soon as this efl!ect is 
produced, all the distressing symptoms usually subside. If in the 
course of an hour or two the difficulty of respiration reappears, and 
the pulse be not soft and feeble, more blood should be drawn, and 
again to the extent of inducing an approach of syncope. I have 
been obliged to open a vein three or four times in the course of 
twelve hours, before a permanent and decisive impression was pro- 
duced on the disease. Such copious depletion is, however, demanded 
only in cases where the local and general inflammatory action is 
strong — where the pulse is tense, hard, quick and vigorous, attended 
with a dry and sonorous cough and respiration. Such cases arc apt 
to terminate in the formation of a false membrane in the larynx ; 
and our efforts ought to be prompt and vigorous to reduce the in- 
flammation below the grade necessary for the formation of pseudo- 
membranous matter. After the effusion which gives rise to the 
membrane has taken place, bleeding will afford but moderate and 
temporary advantage. 

It must also be observed, that where the disease is attended with 
but moderate symptoms of febrile excitement; where the pulse is 
not hard, or tense, though accelerated; and especially where, in ad- 
dition to these manifestations of a moderate febrile excitement, the 
cough and respiration are attended, earli/, with a copious, trans- 
parent and viscid mucus, blood-letting need very seldom be em- 
ployed to the extent just mentioned, and may even, in some instances, 
be wholly dispensed with.* 

Emetics are important remedies in this disease, and may, indeed, 
be regarded as indispensable in its remedial management. Assisted 

* In no country is blood-letting so actively employed in this, as indeed in all 
other indamraaloiy affections, as in America., The value of this evacuation iu 
the present disease has been long understood by American physicians, Avhilst iu 
Europe it was, until lately, looked upon as an equivocal, if not an injurious mea- 
sure. Even those who admitted the inllammatory nature of the disease, bled but 
very sparinaly- To this there are indeed some remarkable exceptions. Ferriar 
recommends bleeding, ad deliquium. {Med. Histories.) "This," says he, " is the 
essential point, without which no relief can be effected." The same practice is 
strongly inculcated by Drs. Bayley and Middleton. {Cases of Angina Trachcalis, 
ivith Ihe Cure, in Lciicrs to William Hunter , M. D., 1781.) And in the late medical 
journals, observations may be found equally favourable to decisive depletory mea- 
sures in this formidable malady. 



326 CYNANCHE TRACHEALIS. 

by warm pediluvia, mercurial purgatives, and rubefacients to the 
throat, 1 have frequently subdued mild attacks of the disease without 
the aid of direct depletion. In those cases that are early attended 
with a copious secretion of viscid mucus in the larynx and trachea, 
emetics are especially useful. They tend not only to expel this 
tough mucus from the larynx, and thus to give a temporary freedom 
from the dyspnoea, but also to equalize the circulation and to pro- 
mote the cutaneous exhalation, as well as to diminish the general 
arterial excitement by the nausea which precedes and accompanies 
their operation. In infants affected with this disease, the occasional 
employment of an emetic is particularly important ; for at this early 
age, no voluntary efforts are made to dislodge and expel the viscid 
secretion from the larynx, and which, if not removed, may by itself 
cause suffocation. In those violent cases, which manifest a highly 
inflammatory character, and in which the cough and respiration are 
drxj during the first stage, there is commonly but little advantage 
gained from the operation of an emetic, so long as this dryness of 
the larynx and trachea continues. In such cases the proper period 
for the administration of emetics commences with the appearance 
of the viscid secretions, which always sooner or later occur in the 
respiratory passages, and from which the disease derives its most 
serious and dangerous character. Without doubt, from the general 
antiphlogistic tendency of nausea and emesis, some benefit may result 
from the exhibition of emetics before any morbid secretions occur 
in the larynx; but the peculiar advantages of this class of remedies 
are most assuredly more conspicuously displayed when the upper 
portions of the windpipe are clogged with a viscid fluid, which 
requires expulsion. In the advanced periods of the disease, there 
exists often so much torpor or insensibility of the system, in conse- 
quence of the imperfect decarbonization of the blood and vascular 
congestion in the brain, that great difficulty is experienced in pro- 
curing the operation of emetics. To obviate this gastric insensibility, 
and procure emesis, we must endeavour to diminish the sanguineous 
congestion in the head; and this may, in general, be readily accom- 
plished by putting the patient's feet in warm water, and applying a 
napkin wet with very cold water, to the head. The abstraction of 
blood, too, while the patient is supported in a sitting or erect posture, 
will rarely fail to ensure the operation of an emetic under the cir- 
cumstances in question. The articles I prefer as an emetic in this 
disease are calomel in combination with tart, antim. I commonly 
administer from five to six grains of the former article with